Provider Demographics
NPI:1942247861
Name:TYBERG, KAY L (GNP)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:L
Last Name:TYBERG
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-4105
Mailing Address - Fax:612-904-4644
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-4105
Practice Address - Fax:612-904-4644
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2006001671363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN025N3TYOtherBLUE CROSS BLUE SHIELD
MN04-08776OtherMEDICA
MN575324400Medicaid
MN500003495Medicare Oscar/Certification
MN575324400Medicaid
MN500003690Medicare Oscar/Certification