Provider Demographics
NPI:1245474667
Name:TYSON, DANIEL LEWIS (IDMT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEWIS
Last Name:TYSON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W CASABLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5009
Mailing Address - Country:US
Mailing Address - Phone:575-784-7801
Mailing Address - Fax:
Practice Address - Street 1:208 W CASABLANCA AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88103-5009
Practice Address - Country:US
Practice Address - Phone:575-784-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians