Healthcare Provider Details

I. General information

NPI: 1548244908
Provider Name (Legal Business Name): ALAN D TYSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8918 BLAKENEY PROFESSIONAL DR SUITE 120
CHARLOTTE NC
28277-6691
US

IV. Provider business mailing address

8918 BLAKENEY PROFESSIONAL DR SUITE 120
CHARLOTTE NC
28277-6691
US

V. Phone/Fax

Practice location:
  • Phone: 704-900-8960
  • Fax: 704-817-9523
Mailing address:
  • Phone: 704-900-8960
  • Fax: 704-817-9523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2487
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: