Provider Demographics
NPI:1871315770
Name:FIKES, TYRA M
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:M
Last Name:FIKES
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 1:1535 S STATE ROUTE 89 APT 103
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-6669
Mailing Address - Country:US
Mailing Address - Phone:928-499-5510
Mailing Address - Fax:
Practice Address - Street 1:1535 S STATE ROUTE 89 APT 103
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-6669
Practice Address - Country:US
Practice Address - Phone:928-499-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBL23-000087202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology