Healthcare Provider Details

I. General information

NPI: 1124315676
Provider Name (Legal Business Name): TYLER SCOTT DEUSER MBA, ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 PARADISE LN
MADISON IN
47250-8801
US

IV. Provider business mailing address

43 PARADISE LN
MADISON IN
47250-8801
US

V. Phone/Fax

Practice location:
  • Phone: 812-599-0942
  • Fax:
Mailing address:
  • Phone: 812-599-0942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001333A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: