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General NPI Number Information
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NPI Number | 1912735192
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Entity Type | Individual
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Provider Name | BRIGHAM TYLER WELLS PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/22/2024
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Last Update Date | 07/31/2024
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Provider Practice Location Address
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Address Line | 3410 ILLINOIS ST
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City | NORTH CHICAGO
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State | IL
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Zip | 60088-3120
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Country | US
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Telephone | 224-610-3886
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Fax |
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Provider Business Mailing Address
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Address Line | 10881 SEASONS PL APT 204
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-1340
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Country | US
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Telephone | 385-223-7433
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 13826251-1206
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License Number State | UT
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