Provider Demographics
NPI:1639440548
Name:TYSON, KRISTIN A (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:TYSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:A
Other - Last Name:LIEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 POND RD
Practice Address - Street 2:STE 401
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-2258
Practice Address - Country:US
Practice Address - Phone:610-398-7700
Practice Address - Fax:610-398-6917
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055148363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical