Provider Demographics
NPI:1255728291
Name:TERRY, TYSON
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:
Last Name:TERRY
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 1:11017 43RD STREET CT E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-2356
Mailing Address - Country:US
Mailing Address - Phone:253-202-0076
Mailing Address - Fax:
Practice Address - Street 1:111 E STEWART AVE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3008
Practice Address - Country:US
Practice Address - Phone:253-845-0543
Practice Address - Fax:253-848-6788
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH 60542623111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor