Provider Demographics
NPI:1215559596
Name:STANDBERRY, TYARE (RDMS RVT)
Entity Type:Individual
Prefix:MRS
First Name:TYARE
Middle Name:
Last Name:STANDBERRY
Suffix:
Gender:F
Credentials:RDMS RVT
Other - Prefix:
Other - First Name:TYARE
Other - Middle Name:
Other - Last Name:STANDBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1049 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-5509
Mailing Address - Country:US
Mailing Address - Phone:601-810-8295
Mailing Address - Fax:
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1436
Practice Address - Country:US
Practice Address - Phone:985-345-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1642302085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
164230OtherARDMS