Provider Demographics
NPI:1003245457
Name:TYSON, VINCENT
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 SE 3RD CT
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-4727
Mailing Address - Country:US
Mailing Address - Phone:516-661-1805
Mailing Address - Fax:
Practice Address - Street 1:5333 N DIXIE HWY STE 110
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3453
Practice Address - Country:US
Practice Address - Phone:954-772-8554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPO13376363LP2300X
FL11005143363LP2300X
WAAP61299531363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care