Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | E5270 | TX |
Y | 2080N0001X | Neonatal-Perinatal Doctor | E5270 | TX |
NPI | 1104862655 |
---|---|
Provider Name | Jon E Tyson |
First Address | Houston, TX 77216-1088 |
Second Address | Houston, TX 77030-3000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 12/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
84511Y | BCBS (01) | TX |
E76883 | (02) | TX |