Provider Demographics
NPI:1295943173
Name:TYSON, SHAWN THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:THOMAS
Last Name:TYSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11037 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3254
Mailing Address - Country:US
Mailing Address - Phone:804-745-8745
Mailing Address - Fax:888-628-6488
Practice Address - Street 1:11037 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3254
Practice Address - Country:US
Practice Address - Phone:804-745-8745
Practice Address - Fax:888-628-6488
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556096111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ75612Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER