Provider Demographics
NPI:1336336759
Name:TYSON, ROBERT JOHN III (LPN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:TYSON
Suffix:III
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 STANDISH DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1913
Mailing Address - Country:US
Mailing Address - Phone:315-477-9593
Mailing Address - Fax:
Practice Address - Street 1:215 STANDISH DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1913
Practice Address - Country:US
Practice Address - Phone:315-477-9593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-30
Last Update Date:2007-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241946164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse