Provider Demographics
NPI:1699819953
Name:TYSON, HOLLY JEN (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEN
Last Name:TYSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1813
Mailing Address - Country:US
Mailing Address - Phone:806-796-0202
Mailing Address - Fax:806-796-0496
Practice Address - Street 1:3811 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1813
Practice Address - Country:US
Practice Address - Phone:806-796-0202
Practice Address - Fax:806-796-0496
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00464OtherSTATE ID NO.
TXPA00464Medicaid
TXPA00464OtherSTATE ID NO.
TX8ON552Medicare ID - Type Unspecified