Healthcare Provider Details

I. General information

NPI: 1932991494
Provider Name (Legal Business Name): TYLER WIMMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 N 1100 E
AMERICAN FORK UT
84003-2090
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-2480
  • Fax: 801-855-4101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12919021-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: