Provider Demographics
NPI:1770057507
Name:BAUMAN, TYLER JOHN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JOHN
Last Name:BAUMAN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 CRESTVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4320
Mailing Address - Country:US
Mailing Address - Phone:952-449-1054
Mailing Address - Fax:
Practice Address - Street 1:1540 6TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4850
Practice Address - Country:US
Practice Address - Phone:952-449-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
920798698OtherMEDICA