MEDICARE: COURTNEY E. TYSON P.A.

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	PA04299	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00J629	OTHER	TX	MEDICARE GROUP

General Provider Information

NPI Number	:	1457343956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY E. TYSON P.A.

Provider Business Mailing Address
First Line	:	125 WEST IH-30
Second Line	:	SUITE L
City	:	ROYSE CITY
State	:	TX
Zip	:	75189
Country	:	US
Telephone Number	:	972-635-9490
Fax Number	:	972-635-2190

Provider Business Practice Location Address
First Line	:	4211 JOE RAMSEY BLVD E
Second Line	:	SUITE 100
City	:	GREENVILLE
State	:	TX
Zip	:	75401-7852
Country	:	US
Telephone Number	:	903-408-7700
Fax Number	:	903-408-7810

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	04/12/2022

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Directions to “ COURTNEY E. TYSON P.A.” Practice Location

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