Provider Demographics
NPI:1649714940
Name:UBBEN, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:UBBEN
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 1:5650 E TABOR DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-9717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5650 E TABOR DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-9717
Practice Address - Country:US
Practice Address - Phone:303-660-9327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO246Z00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other