Healthcare Provider Details

I. General information

NPI: 1992076111
Provider Name (Legal Business Name): BENJAMIN C. TYAU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 BATH RD
BRUNSWICK ME
04011
US

IV. Provider business mailing address

1321 N MARTINGALE RD
GILBERT AZ
85234-1701
US

V. Phone/Fax

Practice location:
  • Phone: 207-424-2272
  • Fax:
Mailing address:
  • Phone: 480-452-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5007
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: