Healthcare Provider Details

I. General information

NPI: 1932971686
Provider Name (Legal Business Name): TY WHEELER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PAYCOR STADIUM
CINCINNATI OH
45202-3492
US

IV. Provider business mailing address

304 E STATE ROUTE A
ARCHIE MO
64725-9766
US

V. Phone/Fax

Practice location:
  • Phone: 573-619-2576
  • Fax:
Mailing address:
  • Phone: 573-619-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT007143
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: