Provider Demographics
NPI:1053073833
Name:TYSON, SETH AARON
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:AARON
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 TOWNSEND ST
Mailing Address - Street 2:
Mailing Address - City:VOLTAIRE
Mailing Address - State:ND
Mailing Address - Zip Code:58792-1703
Mailing Address - Country:US
Mailing Address - Phone:540-845-7922
Mailing Address - Fax:
Practice Address - Street 1:414 TOWNSEND ST
Practice Address - Street 2:
Practice Address - City:VOLTAIRE
Practice Address - State:ND
Practice Address - Zip Code:58792-1703
Practice Address - Country:US
Practice Address - Phone:540-845-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDND4674626Medicaid