Provider Demographics
NPI:1043421936
Name:DEKORSE, TYSON (MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:DEKORSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 W 940 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3301
Mailing Address - Country:US
Mailing Address - Phone:801-357-7940
Mailing Address - Fax:
Practice Address - Street 1:475 W 940 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3301
Practice Address - Country:US
Practice Address - Phone:801-357-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000064568Medicare PIN