Provider Demographics
NPI:1780669218
Name:TYSON, MARY LYNN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1727 WRIGHTSBORO RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4074
Mailing Address - Country:US
Mailing Address - Phone:706-736-8170
Mailing Address - Fax:706-736-8184
Practice Address - Street 1:1727 WRIGHTSBORO RD
Practice Address - Street 2:SUITE B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4074
Practice Address - Country:US
Practice Address - Phone:706-736-8170
Practice Address - Fax:706-736-8184
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-10-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0306832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000902063VMedicaid
GA000606317BMedicaid
GA000902063VMedicaid