Healthcare Provider Details

I. General information

NPI: 1801781042
Provider Name (Legal Business Name): WILLIAM DAVIS TYUS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 E SHOTWELL ST
BAINBRIDGE GA
39819-4146
US

IV. Provider business mailing address

227 CHARLES COR
MEXICO BEACH FL
32456-0201
US

V. Phone/Fax

Practice location:
  • Phone: 229-234-6146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberGAA-NP003760
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberGAA-NP003760
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberAPRN11041775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: