Healthcare Provider Details

I. General information

NPI: 1831665256
Provider Name (Legal Business Name): TYLER BECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TYLER BECKER AT

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N91W15750 FALLS PKWY
MENOMONEE FALLS WI
53051-2301
US

IV. Provider business mailing address

423 GREEN BAY RD
THIENSVILLE WI
53092-1309
US

V. Phone/Fax

Practice location:
  • Phone: 262-532-1100
  • Fax:
Mailing address:
  • Phone: 414-881-1316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1809-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: