Healthcare Provider Details

I. General information

NPI: 1043429111
Provider Name (Legal Business Name): ADAM RICHARD TYSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MAIN ST.
NEW HAMPTON NH
03256-0070
US

IV. Provider business mailing address

PO BOX 70
NEW HAMPTON NH
03256-0070
US

V. Phone/Fax

Practice location:
  • Phone: 603-677-3443
  • Fax:
Mailing address:
  • Phone: 603-677-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0172
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: