Provider Demographics
NPI:1023436409
Name:FOSDICK, TYLER MICHAEL (PT)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:MICHAEL
Last Name:FOSDICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W 29TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-2797
Mailing Address - Country:US
Mailing Address - Phone:970-663-6142
Mailing Address - Fax:970-635-3087
Practice Address - Street 1:107 W 29TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2797
Practice Address - Country:US
Practice Address - Phone:970-663-6142
Practice Address - Fax:970-635-3087
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO350239YSP3Medicare PIN