Provider Demographics
NPI:1245208776
Name:FARIAS, TYRONE (PA)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:FARIAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 863481
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3370 BURNS RD STE 105
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4327
Practice Address - Country:US
Practice Address - Phone:561-630-3570
Practice Address - Fax:561-630-8572
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ41021Medicare UPIN
FLU4511WMedicare ID - Type UnspecifiedMEDICARE