MEDICARE: MR. TYSON RUNAKO ANDERSON MPH, MSN, AGNP-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	363LP2300X	Primary Care Nurse Practitioner	210126497	DC

General Provider Information

NPI Number	:	1619427390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYSON RUNAKO ANDERSON MPH, MSN, AGNP-C

Provider Business Mailing Address
First Line	:	1400 6TH AVE S
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35233-1502
Country	:	US
Telephone Number	:	205-930-1530
Fax Number	:	205-930-0243

Provider Business Practice Location Address
First Line	:	3636 GEORGIA AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20010-1646
Country	:	US
Telephone Number	:	202-446-1100
Fax Number	:	202-204-0806

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

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	07/12/2023

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