Provider Demographics
NPI:1821861287
Name:TYRE, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TYRE
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 1:802 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-4204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:802 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4204
Practice Address - Country:US
Practice Address - Phone:701-683-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic