Provider Demographics
NPI:1861429482
Name:LANGELIERS, TYSON LEE (PA -C, ATC, LAT)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:LEE
Last Name:LANGELIERS
Suffix:
Gender:M
Credentials:PA -C, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3300
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-3300
Mailing Address - Country:US
Mailing Address - Phone:541-536-3435
Mailing Address - Fax:
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739
Practice Address - Country:US
Practice Address - Phone:541-536-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2232255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer