Provider Demographics
NPI:1285856005
Name:TYSON, ROSE MARIE (RN, ANP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE MARIE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:RN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:L-603
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-5626
Mailing Address - Fax:503-494-5627
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:L-603
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-5626
Practice Address - Fax:503-494-5627
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090000307N3 ANP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health