Healthcare Provider Details

I. General information

NPI: 1013508167
Provider Name (Legal Business Name): AMANDA MARIE TYRA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # AD-2226
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST # AD-2226
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-446-4887
  • Fax: 706-723-0382
Mailing address:
  • Phone: 706-446-4887
  • Fax: 706-723-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10133
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: