Provider Demographics
NPI:1932256146
Name:TYSON, ANNE G (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNE
Middle Name:G
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 S FLORIDA AVE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3327
Mailing Address - Country:US
Mailing Address - Phone:863-648-0500
Mailing Address - Fax:863-644-9015
Practice Address - Street 1:6700 S FLORIDA AVE
Practice Address - Street 2:SUITE 13
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3327
Practice Address - Country:US
Practice Address - Phone:863-648-0500
Practice Address - Fax:863-644-9015
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME61703OtherLICENSE #
FLME61703OtherLICENSE #
FL17701Medicare ID - Type Unspecified
FLME61703OtherLICENSE #