1720342272 NPI number — MR. CRAIG ALLEN TYSON SR. PMHNP-BC

Table of content: MR. CRAIG ALLEN TYSON SR. PMHNP-BC (NPI 1720342272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720342272 NPI number — MR. CRAIG ALLEN TYSON SR. PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYSON
Provider First Name:
CRAIG
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720342272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 GREENBRIER CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-2640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-9007
Provider Business Mailing Address Fax Number:
757-548-1928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 GREENBRIER CIR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-547-9007
Provider Business Practice Location Address Fax Number:
757-548-1928
Provider Enumeration Date:
06/29/2012

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: 363LP0808X , with the licence number:  0024169876 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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