Basic Information
| Provider Information | |||||||||
| NPI: | 1598349243 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BLUDAU | ||||||||
| FirstName: | TYLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7505 N LOOP 1604 E STE 101 | ||||||||
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| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782332604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105904000 | ||||||||
| FaxNumber: | 2105904585 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 CYPRESS CREEK RD STE B1 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786134477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129180044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2021 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.