Provider Demographics
NPI:1346760220
Name:TYSON, MEGAN WALLACE (NP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:WALLACE
Last Name:TYSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E FORTIFICATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily