Provider Demographics
NPI:1265073761
Name:ROCKWELL, TYSON B
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:B
Last Name:ROCKWELL
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 1:370 CULROSS CIR
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8166
Mailing Address - Country:US
Mailing Address - Phone:435-840-2767
Mailing Address - Fax:
Practice Address - Street 1:455 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2753
Practice Address - Country:US
Practice Address - Phone:801-328-6033
Practice Address - Fax:435-328-6027
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7338418-17012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer