Provider Demographics
NPI:1245820679
Name:SHAFER, TYLER DANIEL (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:DANIEL
Last Name:SHAFER
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18895 ENGLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8139
Mailing Address - Country:US
Mailing Address - Phone:651-304-7725
Mailing Address - Fax:
Practice Address - Street 1:310 SMITH AVE N STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2383
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program