Provider Demographics
NPI:1801423140
Name:TYSON, DEMARE
Entity type:Individual
Prefix:
First Name:DEMARE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E MOUNT AIRY AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-1142
Mailing Address - Country:US
Mailing Address - Phone:267-886-3906
Mailing Address - Fax:
Practice Address - Street 1:1601 E MOUNT AIRY AVE APT 2B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-1142
Practice Address - Country:US
Practice Address - Phone:267-886-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide