Provider Demographics
NPI:1992878789
Name:HIGGINSON, TYLER G (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:G
Last Name:HIGGINSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109B E CAPITOL DR STE 1
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8726
Mailing Address - Country:US
Mailing Address - Phone:920-202-3371
Mailing Address - Fax:920-939-3827
Practice Address - Street 1:710 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1941
Practice Address - Country:US
Practice Address - Phone:715-256-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR79716367500000X
WI3410-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC011417052OtherDRIVERS LICENSE