Provider Demographics
NPI:1912628520
Name:WILSON, TYLER LYNN GROMANN (PTA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:LYNN GROMANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BALCONES DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4737
Mailing Address - Country:US
Mailing Address - Phone:817-733-0235
Mailing Address - Fax:
Practice Address - Street 1:1101 RAINTREE CIR STE 150
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4957
Practice Address - Country:US
Practice Address - Phone:214-509-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2149078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant