1275024432 NPI number — TYRA LARAE JONS ATC

Table of content: TYRA LARAE JONS ATC (NPI 1275024432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275024432 NPI number — TYRA LARAE JONS ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONS
Provider First Name:
TYRA
Provider Middle Name:
LARAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PATZLAFF
Provider Other First Name:
TYRA
Provider Other Middle Name:
LARAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275024432
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12455 US HIGHWAY 16A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUSTER
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57730-8357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-770-0390
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 CAREGIVER CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57702-8529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-755-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , with the licence number: 0592 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01324319 . This is a "DRIVERS LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".