Provider Demographics
NPI:1376858209
Name:NIELSON, TYRELL P (PA-C)
Entity Type:Individual
Prefix:
First Name:TYRELL
Middle Name:P
Last Name:NIELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-8931
Mailing Address - Country:US
Mailing Address - Phone:509-837-0070
Mailing Address - Fax:509-837-0690
Practice Address - Street 1:2935 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8931
Practice Address - Country:US
Practice Address - Phone:509-837-0070
Practice Address - Fax:509-837-0690
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOA60349888363A00000X
IDPA1269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010279Medicaid