Healthcare Provider Details

I. General information

NPI: 1306236492
Provider Name (Legal Business Name): JARED J TYSON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RENAISSANCE TOWNE DR SUITE 400
BOUNTIFUL UT
84010-7667
US

IV. Provider business mailing address

1551 RENAISSANCE TOWNE DR SUITE 400
BOUNTIFUL UT
84010-7667
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-7200
  • Fax: 801-295-4930
Mailing address:
  • Phone: 801-295-7200
  • Fax: 801-295-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8915908-1205
License Number StateUT

VIII. Authorized Official

Name: ANNETTE SIMMONS
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-295-7200