MEDICARE: DEMARE TYSON

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	374U00000X	Home Health Aide		PA

General Provider Information

NPI Number	:	1801423140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMARE TYSON

Provider Business Mailing Address
First Line	:	1601 E MOUNT AIRY AVE APT 2B
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-1142
Country	:	US
Telephone Number	:	267-886-3906
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 E MOUNT AIRY AVE APT 2B
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-1142
Country	:	US
Telephone Number	:	267-886-3906
Fax Number	:

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

Provider Enumeration Date	:	03/25/2020
Last Update Date	:	04/10/2020

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Directions to “ DEMARE TYSON ” Practice Location

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