Provider Demographics
NPI:1083698518
Name:TYSER, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TYSER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S 48TH ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1200
Mailing Address - Country:US
Mailing Address - Phone:402-483-8600
Mailing Address - Fax:402-483-8689
Practice Address - Street 1:1500 S 48TH ST STE 800
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1200
Practice Address - Country:US
Practice Address - Phone:402-483-8600
Practice Address - Fax:402-483-8689
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1215363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026945501Medicaid
NE250859OtherMIDLANDS CHOICE FOR CCH
NE250859OtherMIDLANDS CHOICE FOR CCH
NE39083OtherBCBS NE FOR CCH
NE281796Medicare PIN