Provider Demographics
NPI:1245019017
Name:NADEAU, TYSON DANIEL
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:DANIEL
Last Name:NADEAU
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 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2693
Mailing Address - Country:US
Mailing Address - Phone:207-283-0171
Mailing Address - Fax:
Practice Address - Street 1:10 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-4130
Practice Address - Country:US
Practice Address - Phone:207-590-2569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant