Provider Demographics
NPI:1043277023
Name:TYSON, JAMES A (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:TYSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:207-734-5036
Practice Address - Street 1:788 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6856
Practice Address - Country:US
Practice Address - Phone:208-734-1281
Practice Address - Fax:208-734-1282
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-20-2207103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1550910Medicare Oscar/Certification
IDQ43424Medicare UPIN
ID1550919Medicare Oscar/Certification