Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath |
NPI | 1154619856 |
---|---|
Provider Name | Dr. Kirt Tyson |
First Address | Mesa, AZ 85201-6600 |
Second Address | Mesa, AZ 85201-6600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2011 |
Last Update Date | 08/12/2011 |