Provider Demographics
NPI:1093479552
Name:SMITH, TYCEN (PA-C)
Entity Type:Individual
Prefix:
First Name:TYCEN
Middle Name:
Last Name:SMITH
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 1:1250 W 75TH ST APT 311
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2991
Mailing Address - Country:US
Mailing Address - Phone:419-239-7891
Mailing Address - Fax:
Practice Address - Street 1:33300 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1172
Practice Address - Country:US
Practice Address - Phone:440-695-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007259RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant