Provider Demographics
NPI:1992195820
Name:TRUXTON, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TRUXTON
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 1:2109 BRITTANY DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9794
Mailing Address - Country:US
Mailing Address - Phone:616-558-2005
Mailing Address - Fax:
Practice Address - Street 1:2109 BRITTANY DR NE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-9794
Practice Address - Country:US
Practice Address - Phone:616-558-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer