MEDICARE: MR. TYSON HOLT WARNER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA 9103507	FL

General Provider Information

NPI Number	:	1053502054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYSON HOLT WARNER PA-C

Provider Business Mailing Address
First Line	:	18260 N BAY RD
Second Line	:	# 512
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-2743
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18260 N BAY RD
Second Line	:	# 512
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-2743
Country	:	US
Telephone Number	:	954-260-7421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	03/07/2008

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