Provider Demographics
NPI:1740270446
Name:HAUSWALD, TYLER D (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:D
Last Name:HAUSWALD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 COUNTY ROAD J
Mailing Address - Street 2:SAUNDERS MEDICAL CENTER
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-4152
Mailing Address - Country:US
Mailing Address - Phone:402-443-4191
Mailing Address - Fax:402-443-1440
Practice Address - Street 1:1760 COUNTY ROAD J
Practice Address - Street 2:SAUNDERS MEDICAL CENTER
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-4152
Practice Address - Country:US
Practice Address - Phone:402-443-4191
Practice Address - Fax:402-443-1440
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE00935363A00000X
NE935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE236616OtherMIDLANDS CHOICE
NE06685OtherBLUE CROSS BLUE SHIELD
NE554935245Medicaid
275953Medicare PIN
NEP68339Medicare UPIN
NE236616OtherMIDLANDS CHOICE
275953Medicare Oscar/Certification