Provider Demographics
NPI:1558569764
Name:TYSON, PATRICE JENNE (MD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:JENNE
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 409
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-6834
Mailing Address - Fax:225-765-2054
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 409
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-6834
Practice Address - Fax:225-765-2054
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090026208000000X
LAMD.0257832080P0206X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1044121Medicaid
OH000000530761OtherANTHEM
OH000000225140OtherUNISON
OH415048OtherWELLCARE
OH749095OtherBUCKEYE
OH2745551Medicaid
OH962065OtherAETNA
MS03659802Medicaid
PA1021891110001OtherPA MEDICAID
4Q424BD11Medicare PIN
OHT44215871Medicare PIN
OHTY4215872Medicare PIN