Provider Demographics
NPI:1629748645
Name:GREGSON, TY JULIAN
Entity Type:Individual
Prefix:MR
First Name:TY
Middle Name:JULIAN
Last Name:GREGSON
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 1:1111 DITMARS RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-7900
Mailing Address - Country:US
Mailing Address - Phone:479-438-2203
Mailing Address - Fax:
Practice Address - Street 1:1015 W WASHBOURNE ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-4205
Practice Address - Country:US
Practice Address - Phone:918-308-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator