Provider Demographics
NPI:1811325228
Name:MANSBERGER, TYLER DWANE (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:DWANE
Last Name:MANSBERGER
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 1:4133 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BROAD TOP
Mailing Address - State:PA
Mailing Address - Zip Code:16621-9001
Mailing Address - Country:US
Mailing Address - Phone:814-635-2916
Mailing Address - Fax:814-635-2918
Practice Address - Street 1:6678 TOWNE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-6934
Practice Address - Country:US
Practice Address - Phone:814-506-8490
Practice Address - Fax:814-506-8493
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056247363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008434780002Medicaid
PA400472OtherHUMANA
PA102926115-0003Medicaid
PA102926115-0006Medicaid
PA102926115-0007Medicaid
PA102926115-0008Medicaid
PA102926115-0002Medicaid
PA754008OtherPART-B PTAN
PA102926115-0005Medicaid
PA102926115-0004Medicaid
PA102926115-0009Medicaid
PA709708OtherAMERIHEALTH CARITAS