Provider Demographics
NPI:1952354839
Name:TYSON, INGRID MARIA (MS FNP)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:MARIA
Last Name:TYSON
Suffix:
Gender:F
Credentials:MS FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 PRINCIPE DE PAZ
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9211
Mailing Address - Country:US
Mailing Address - Phone:505-780-5425
Mailing Address - Fax:
Practice Address - Street 1:780 2ND ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-8354
Practice Address - Country:US
Practice Address - Phone:541-347-2529
Practice Address - Fax:541-347-9196
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273956Medicaid
OR120353OtherMEDICARE GROUP PIN
ORMT1263475OtherDEA NUMBER
OR120353OtherMEDICARE GROUP PIN
ORMT1263475OtherDEA NUMBER
ORP33799Medicare UPIN