Individual
MR. TYSON RECORDS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1717 S J ST, TACOMA, WA 98405-4933
(844) 364-2778
(253) 566-8777
Mailing address
1717 S J ST, TACOMA, WA 98405-4933
(844) 364-2778
(253) 566-8777
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA60310447
WA
363AS0400X
Surgical Physician Assistant
014858
NY
363AS0400X
Surgical Physician Assistant
PA60310447
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2023512
—
WA
Enumeration date
03/07/2012
Last updated
12/09/2020
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