Provider Demographics
NPI:1376420570
Name:TYSON, SHAWNER (PHLEBOTOMIST)
Entity type:Individual
Prefix:
First Name:SHAWNER
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-4482
Mailing Address - Country:US
Mailing Address - Phone:601-441-8326
Mailing Address - Fax:601-860-9834
Practice Address - Street 1:665 S PEAR ORCHARD RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4861
Practice Address - Country:US
Practice Address - Phone:601-921-5081
Practice Address - Fax:601-860-9834
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS063018-PWECW15312246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy