MEDICARE: MICHELLE ASANTEWA TYSON MD

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	207Q00000X	Family Medicine Physician	A72333	CA

General Provider Information

NPI Number	:	1689672370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ASANTEWA TYSON MD

Provider Business Mailing Address
First Line	:	2661 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1412
Country	:	US
Telephone Number	:	626-798-4952
Fax Number	:	626-798-5260

Provider Business Practice Location Address
First Line	:	2661 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1412
Country	:	US
Telephone Number	:	626-798-4952
Fax Number	:	626-798-5260

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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Directions to “ MICHELLE ASANTEWA TYSON MD” Practice Location

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