Provider Demographics
NPI:1912521113
Name:AMBORN, TYLER (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:AMBORN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 HARRIS DR UNIT 6
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9017
Mailing Address - Country:US
Mailing Address - Phone:715-314-1115
Mailing Address - Fax:
Practice Address - Street 1:2999 N MAYFAIR RD # 300
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4306
Practice Address - Country:US
Practice Address - Phone:414-479-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist