Healthcare Provider Details

I. General information

NPI: 1245492800
Provider Name (Legal Business Name): TYGH WYCKOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 116TH AVE NE
BELLEVUE WA
98004-4604
US

IV. Provider business mailing address

PO BOX 24503
SEATTLE WA
98124-0503
US

V. Phone/Fax

Practice location:
  • Phone: 425-822-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMT190162
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD60273276
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: