Healthcare Provider Details

I. General information

NPI: 1366272007
Provider Name (Legal Business Name): TYLER VANDEN BOOGARD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S JEFFERSON ST
VERONA WI
53593-1493
US

IV. Provider business mailing address

5123 CENTRAL PARK PL APT 101
FITCHBURG WI
53711-9314
US

V. Phone/Fax

Practice location:
  • Phone: 608-845-6465
  • Fax:
Mailing address:
  • Phone: 920-359-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16547-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: