Healthcare Provider Details

I. General information

NPI: 1366488249
Provider Name (Legal Business Name): MARY P. TYREE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S 10TH ST
HAINES CITY FL
33844-5602
US

IV. Provider business mailing address

2600 S DOUGLAS RD STE 308
CORAL GABLES FL
33134-6134
US

V. Phone/Fax

Practice location:
  • Phone: 863-547-0755
  • Fax:
Mailing address:
  • Phone: 561-244-3643
  • Fax: 863-606-6737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102323
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: