Provider Demographics
NPI:1902416480
Name:SHIMEK, TYLER WILLIAM
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WILLIAM
Last Name:SHIMEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 QUARRY PARK DR APT 4
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8192
Mailing Address - Country:US
Mailing Address - Phone:920-901-9496
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-901-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
WI131883367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program