Provider Demographics
NPI:1881019925
Name:KINNICK, TYSON RAND (PBT(ASCP), PHD, PA-C)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:RAND
Last Name:KINNICK
Suffix:
Gender:M
Credentials:PBT(ASCP), PHD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5647 US HIGHWAY 26
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:WY
Mailing Address - Zip Code:82513-9607
Mailing Address - Country:US
Mailing Address - Phone:307-455-2516
Mailing Address - Fax:
Practice Address - Street 1:128 MARKET ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2290
Practice Address - Country:US
Practice Address - Phone:719-587-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002413363A00000X
COPA.0008078363A00000X
WY986363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY986OtherWY LICENSE NUMBER
1881019925OtherNPI NUMBER
IL085.005762OtherILLINOIS LICENSE NUMBER