Provider Demographics
NPI:1972194751
Name:NICKELSON, TYSON RYLEY
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:RYLEY
Last Name:NICKELSON
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 1:3517 CHURCHILL WAY
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-0384
Mailing Address - Country:US
Mailing Address - Phone:785-236-9632
Mailing Address - Fax:
Practice Address - Street 1:200 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-3049
Practice Address - Country:US
Practice Address - Phone:785-539-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79960-011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner