Provider Demographics
NPI:1336613231
Name:WHITWORTH, TYLER JOSEPH WAYNE
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JOSEPH WAYNE
Last Name:WHITWORTH
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 1:200 ROOSEVELT CIR APT 206
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-1517
Mailing Address - Country:US
Mailing Address - Phone:417-684-3149
Mailing Address - Fax:
Practice Address - Street 1:200 ROOSEVELT CIR APT 206
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-1517
Practice Address - Country:US
Practice Address - Phone:417-684-3149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program