Provider Demographics
NPI:1205865045
Name:TYSON, TRACY (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLAIR PARK RD STE 285
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-288-1140
Mailing Address - Fax:802-288-1144
Practice Address - Street 1:11 CREST RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9701
Practice Address - Country:US
Practice Address - Phone:802-527-8189
Practice Address - Fax:802-527-8187
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96031207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275570000Medicaid
FL57012OtherBCBS
GA202194472AMedicaid
FL57012OtherBCBS
FL275570000Medicaid