Provider Demographics
NPI:1225246721
Name:TYSON, KATHERINE SUZANNE (MD,MED)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUZANNE
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD,MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7130 GLEN FOREST DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3754
Mailing Address - Country:US
Mailing Address - Phone:804-662-6060
Mailing Address - Fax:804-282-8678
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE 400
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-288-4084
Practice Address - Fax:804-282-2601
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1225246721Medicaid
VAVAA113147Medicare PIN