Provider Demographics
NPI:1245633585
Name:HANSON, TYLER (ATC)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 PRAIRIE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7314
Mailing Address - Country:US
Mailing Address - Phone:952-944-5314
Mailing Address - Fax:952-944-0092
Practice Address - Street 1:775 PRAIRIE CENTER DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7314
Practice Address - Country:US
Practice Address - Phone:952-944-5314
Practice Address - Fax:952-944-0092
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer