Provider Demographics
NPI:1871642470
Name:PETRE, TYSEN J (DO)
Entity Type:Individual
Prefix:
First Name:TYSEN
Middle Name:J
Last Name:PETRE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1443
Mailing Address - Country:US
Mailing Address - Phone:660-665-4432
Mailing Address - Fax:660-956-4392
Practice Address - Street 1:800 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-1443
Practice Address - Country:US
Practice Address - Phone:660-665-4432
Practice Address - Fax:660-956-4392
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006004444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBNDDOther400608434