Healthcare Provider Details

I. General information

NPI: 1710583596
Provider Name (Legal Business Name): RYAN MARTIN TYNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6799 GREAT OAKS RD STE 100
MEMPHIS TN
38138-2571
US

IV. Provider business mailing address

3838 CENTER HILL CV
OLIVE BRANCH MS
38654-8713
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-0405
  • Fax:
Mailing address:
  • Phone: 901-605-6859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: