Provider Demographics
NPI:1114469871
Name:DUDLEY, TYSON
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:DUDLEY
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 1:1410 NE CAMPUS PARKWAY SEATTLE WA 98195 5852
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-5852
Mailing Address - Country:US
Mailing Address - Phone:425-245-1713
Mailing Address - Fax:
Practice Address - Street 1:1410 NE CAMPUS PARKWAY SEATTLE WA 98195 5852
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-5852
Practice Address - Country:US
Practice Address - Phone:425-245-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60588172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist