Provider Demographics
NPI:1710638374
Name:CATMULL, TYSON WILLIAM (NP-C)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:WILLIAM
Last Name:CATMULL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6777 W DUSTIN CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6933
Mailing Address - Country:US
Mailing Address - Phone:801-694-1743
Mailing Address - Fax:
Practice Address - Street 1:6777 W DUSTIN CIR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6933
Practice Address - Country:US
Practice Address - Phone:801-694-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7717929-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily