Provider Demographics
NPI:1366272007
Name:VANDEN BOOGARD, TYLER (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VANDEN BOOGARD
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 1:5123 CENTRAL PARK PL APT 101
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-9314
Mailing Address - Country:US
Mailing Address - Phone:920-359-0612
Mailing Address - Fax:
Practice Address - Street 1:303 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1493
Practice Address - Country:US
Practice Address - Phone:608-845-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16547-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist