Provider Demographics
NPI:1043579246
Name:TYSON, MEISHELLE BOST (PTA)
Entity Type:Individual
Prefix:
First Name:MEISHELLE
Middle Name:BOST
Last Name:TYSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 J.K. POWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472
Mailing Address - Country:US
Mailing Address - Phone:910-499-2563
Mailing Address - Fax:
Practice Address - Street 1:82 JK POWELL RD
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3115
Practice Address - Country:US
Practice Address - Phone:910-499-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant