Provider Demographics
NPI:1699594887
Name:BUZZARD, TYLER LEE
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:LEE
Last Name:BUZZARD
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 1:2962 OMRO RD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-9301
Mailing Address - Country:US
Mailing Address - Phone:815-980-3872
Mailing Address - Fax:
Practice Address - Street 1:800 ALGOMA BLVD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3551
Practice Address - Country:US
Practice Address - Phone:920-424-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1104664163WC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine