Provider Demographics
NPI:1407906720
Name:TYSON, LAMONT
Entity Type:Individual
Prefix:MR
First Name:LAMONT
Middle Name:
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 B CROMWELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5436
Mailing Address - Country:US
Mailing Address - Phone:252-830-2094
Mailing Address - Fax:252-355-7358
Practice Address - Street 1:700 B CROMWELL DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5436
Practice Address - Country:US
Practice Address - Phone:252-830-2094
Practice Address - Fax:252-355-7358
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4816227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012AGOtherBCBS
NC561924070OtherTAX ID
NC7492717Medicaid