Provider Demographics
NPI:1013508167
Name:TYRA, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:TYRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST # AD-2226
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-446-4887
Mailing Address - Fax:706-723-0382
Practice Address - Street 1:1120 15TH ST # AD-2226
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-446-4887
Practice Address - Fax:706-723-0382
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant