Healthcare Provider Details

I. General information

NPI: 1194889394
Provider Name (Legal Business Name): KATHERINE R TYRIVER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 TURKEY LAKE RD
ORLANDO FL
32819-8001
US

IV. Provider business mailing address

PO BOX 628296
ORLANDO FL
32862-8296
US

V. Phone/Fax

Practice location:
  • Phone: 407-351-8500
  • Fax: 904-346-0113
Mailing address:
  • Phone: 407-741-9418
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA91012431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: