Healthcare Provider Details

I. General information

NPI: 1245079607
Provider Name (Legal Business Name): TYLER BULLARD-WOLF
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD STE 3J018
AUSTIN TX
78723-3051
US

IV. Provider business mailing address

DELL MEDICAL SCHOOL GME OFFICE 1501 RED RIVER STREET, 2ND FLOOR
AUSTIN TX
78729
US

V. Phone/Fax

Practice location:
  • Phone: 512-495-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10088328
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: