Provider Demographics
NPI:1750016879
Name:SMITH, TYSON SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 W 3RD ST STE 990W
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6116
Mailing Address - Country:US
Mailing Address - Phone:310-423-5900
Mailing Address - Fax:
Practice Address - Street 1:325 CORDOVA ST APT 324
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-4692
Practice Address - Country:US
Practice Address - Phone:801-473-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant