Provider Demographics
NPI:1902071285
Name:PAULICK, TY EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:EVAN
Last Name:PAULICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 HIGHWAY 61 N
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2737
Mailing Address - Country:US
Mailing Address - Phone:651-762-5433
Mailing Address - Fax:651-762-7504
Practice Address - Street 1:4801 HIGHWAY 61 N
Practice Address - Street 2:SUITE 105
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2737
Practice Address - Country:US
Practice Address - Phone:651-762-5433
Practice Address - Fax:651-762-7504
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5105111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350004088Medicaid