Healthcare Provider Details

I. General information

NPI: 1255538534
Provider Name (Legal Business Name): TYRA LANEE TYSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYRA LANEE DIGGS MD

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 AUGUSTA ROAD
BEECH ISLAND SC
29842
US

IV. Provider business mailing address

4645 AUGUSTA RD
BEECH ISLAND SC
29842-7265
US

V. Phone/Fax

Practice location:
  • Phone: 803-593-9283
  • Fax: 803-593-0607
Mailing address:
  • Phone: 803-593-9283
  • Fax: 803-593-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME 107184
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: