Healthcare Provider Details

I. General information

NPI: 1598745929
Provider Name (Legal Business Name): JOEL L TYSER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SOUTH HOSPITAL DRIVE
FULTON MO
65251
US

IV. Provider business mailing address

10 SOUTH HOSPITAL DRIVE
FULTON MO
65251
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-3376
  • Fax: 573-592-6679
Mailing address:
  • Phone: 573-642-3376
  • Fax: 573-592-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number078835
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: