Healthcare Provider Details

I. General information

NPI: 1639399611
Provider Name (Legal Business Name): TYLER WRIGHT LANDGRAF MSED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE FORSYTHE RM 109
SPRINGFIELD MO
65897-0027
US

IV. Provider business mailing address

901 S NATIONAL AVE FORSYTHE RM 109
SPRINGFIELD MO
65897-0027
US

V. Phone/Fax

Practice location:
  • Phone: 417-576-8009
  • Fax:
Mailing address:
  • Phone: 417-576-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2009009431
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: