Provider Demographics
NPI:1033450333
Name:TYNES, RONALD PRICE JR (AGACNP)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:PRICE
Last Name:TYNES
Suffix:JR
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-425-5544
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5800
Practice Address - Fax:601-261-3530
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS871257363LA2100X
MSR871257363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08439781Medicaid
MS9811941OtherAETNA
MS3593185OtherUNITED HEALTHCARE
MS8609841OtherCIGNA
MS972790OtherWINDSOR
MSP01206666OtherRAILROAD MEDICARE
MS08439781Medicaid