Provider Demographics
NPI:1295843696
Name:TYNAN, RICHARD OWEN (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:OWEN
Last Name:TYNAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WILSON STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-4137
Mailing Address - Fax:252-338-0366
Practice Address - Street 1:900 WILSON STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-4137
Practice Address - Fax:252-338-0366
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1930111N00000X
NY6001111N00000X
CO4218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908863Medicaid
029695Medicare UPIN
NC8908863Medicaid