Provider Demographics
NPI:1609843572
Name:BROWN, S TYRUS C (PA)
Entity Type:Individual
Prefix:
First Name:S TYRUS
Middle Name:C
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FRANKLIN SPRINGS STREET
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662
Mailing Address - Country:US
Mailing Address - Phone:706-245-7371
Mailing Address - Fax:706-245-9257
Practice Address - Street 1:132 FRANKLIN SPRINGS ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4134
Practice Address - Country:US
Practice Address - Phone:706-245-7371
Practice Address - Fax:706-245-9257
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA646193337BMedicaid
GAS65382Medicare UPIN
GA646193337BMedicaid