Provider Demographics
NPI:1861050445
Name:WILSMAN, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WILSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:VIRDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62690-1319
Mailing Address - Country:US
Mailing Address - Phone:815-883-1259
Mailing Address - Fax:
Practice Address - Street 1:2300 W WHITE OAKS DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6423
Practice Address - Country:US
Practice Address - Phone:217-698-8153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3388237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3388OtherILLINOIS DEPARTMENT OF PUBLIC HEALTH- HEARING INSTRUMENT DISPENSER