Provider Demographics
NPI:1629250519
Name:HENSEL, TYSON EARL (IDC)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:EARL
Last Name:HENSEL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MCLB BARSTOW BLDG 17
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-5008
Mailing Address - Country:US
Mailing Address - Phone:760-577-6491
Mailing Address - Fax:
Practice Address - Street 1:MCLB BARSTOW BLDG 17
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-5008
Practice Address - Country:US
Practice Address - Phone:760-577-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman