Provider Demographics
NPI:1508343732
Name:ANDELIN, TYSON
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:ANDELIN
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 1:605 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1893
Mailing Address - Country:US
Mailing Address - Phone:509-765-0674
Mailing Address - Fax:509-764-0344
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1893
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:509-764-0344
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPENDING363A00000X
WAPA60875340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant