Provider Demographics
NPI:1508857095
Name:TYNAN, KATHRYN M (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:TYNAN
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 1:3672 N WHITE PEARL LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749-9707
Mailing Address - Country:US
Mailing Address - Phone:520-245-3326
Mailing Address - Fax:520-751-6448
Practice Address - Street 1:5757 PLAZA DR
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5000
Practice Address - Country:US
Practice Address - Phone:763-361-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN081159363LA2200X
OR200550137NP363LA2200X
OR200550138NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ440777Medicaid
AZS53497Medicare UPIN