Provider Demographics
NPI:1356806970
Name:COMEAUX, TYRELL ANTHONY (MS, RD)
Entity type:Individual
Prefix:MR
First Name:TYRELL
Middle Name:ANTHONY
Last Name:COMEAUX
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14030 SW BURLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2362
Mailing Address - Country:US
Mailing Address - Phone:503-707-6164
Mailing Address - Fax:
Practice Address - Street 1:24800 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-674-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10178292133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered