1962776088 NPI number — MR. TYSON RECORDS PA-C

Table of content: MR. TYSON RECORDS PA-C (NPI 1962776088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962776088 NPI number — MR. TYSON RECORDS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RECORDS
Provider First Name:
TYSON
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1962776088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 S J ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-364-2778
Provider Business Mailing Address Fax Number:
253-566-8777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 S J ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-364-2778
Provider Business Practice Location Address Fax Number:
253-566-8777
Provider Enumeration Date:
03/07/2012

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: 363AS0400X , with the licence number:  PA60310447 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 014858 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA60310447 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2023512 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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