Healthcare Provider Details

I. General information

NPI: 1699594887
Provider Name (Legal Business Name): TYLER LEE BUZZARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALGOMA BLVD
OSHKOSH WI
54901-3551
US

IV. Provider business mailing address

2962 OMRO RD
OSHKOSH WI
54904-9301
US

V. Phone/Fax

Practice location:
  • Phone: 920-424-1234
  • Fax:
Mailing address:
  • Phone: 815-980-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1104664
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: