Provider Demographics
NPI:1982937330
Name:SAM, TYSON JAYE (AA IN PSYCHOLOGY)
Entity Type:Individual
Prefix:MR
First Name:TYSON
Middle Name:JAYE
Last Name:SAM
Suffix:
Gender:M
Credentials:AA IN PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5608 ZUNI RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2926
Mailing Address - Country:US
Mailing Address - Phone:505-262-6565
Mailing Address - Fax:505-255-9066
Practice Address - Street 1:5608 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2926
Practice Address - Country:US
Practice Address - Phone:505-262-6565
Practice Address - Fax:505-255-9066
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850336893OtherITIN