Provider Demographics
NPI:1720449713
Name:TYSON, MARK (PARAMEDIC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TYSON
Suffix:
Gender:M
Credentials:PARAMEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 E HOSMER ST
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4164
Mailing Address - Country:US
Mailing Address - Phone:815-505-3246
Mailing Address - Fax:
Practice Address - Street 1:1007 E HOSMER ST
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4164
Practice Address - Country:US
Practice Address - Phone:815-505-3246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060204401341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance