Provider Demographics
NPI:1053502054
Name:WARNER, TYSON HOLT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TYSON
Middle Name:HOLT
Last Name:WARNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18260 N BAY RD
Mailing Address - Street 2:# 512
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18260 N BAY RD
Practice Address - Street 2:# 512
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-2743
Practice Address - Country:US
Practice Address - Phone:954-260-7421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant