Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 11005143 | FL |
N | 363LP2300X | Nurse Practitioner - Primary Care | SPO13376 | PA |
NPI | 1003245457 |
---|---|
Provider Name | Vincent Tyson |
First Address | Oakland Park, FL 33334-3453 |
Second Address | Oakland Park, FL 33334-3453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2013 |
Last Update Date | 02/09/2020 |