Provider Demographics
NPI:1184866501
Name:ANDERSON, TYRONE JAMES
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:JAMES
Last Name:ANDERSON
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 1:1310 TULLY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-3054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 TULLY RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-3054
Practice Address - Country:US
Practice Address - Phone:408-379-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator