| Doctor Name: | TYLER WISHAU |
| NPI Number: | 1144649856 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 12303 Depaul Dr. Bridgeton, MO - 630442588 |
| Business Phone Number: | 3143446000 |
| Business Fax Number: | |
| Mailing Address: | 12303 Depaul Dr., BRIDGETON |
| State: | MO |
| Postal Code: | 630442588 |
| Phone Number: | 3143446000 |
| Fax Number: | |
| NPI Enumeration Date: | 04/09/2014 |
| NPI Last Update Date: | 04/09/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |