Provider Demographics
NPI:1417780545
Name:BRUECKMAN, TYLER (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:BRUECKMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 SCARFF RD
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-8675
Mailing Address - Country:US
Mailing Address - Phone:937-543-2255
Mailing Address - Fax:
Practice Address - Street 1:2066 W MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2882
Practice Address - Country:US
Practice Address - Phone:937-372-7583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000872611RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty