Healthcare Provider Details

I. General information

NPI: 1245988583
Provider Name (Legal Business Name): MATTHEW ANTHONY TYREE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

164 BEAR CREEK TRL
MANSFIELD GA
30055-3311
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax:
Mailing address:
  • Phone: 678-449-9418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN235503
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberRN235503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: