Provider Demographics
NPI:1780654194
Name:TRYON, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TRYON
Suffix:
Gender:M
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 1:2300 53RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7564
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:563-324-0615
Practice Address - Street 1:2300 53RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7564
Practice Address - Country:US
Practice Address - Phone:563-322-0971
Practice Address - Fax:563-324-0615
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001501363AS0400X, 363A00000X
IL085002028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400123922Medicare PIN
IA578210032Medicare PIN
IAP98364Medicare UPIN