Provider Demographics
NPI:1063590453
Name:TYC, MATTHEW A
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:TYC
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 1:1516 WASHINGTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2215
Mailing Address - Country:US
Mailing Address - Phone:319-365-9830
Mailing Address - Fax:319-365-9860
Practice Address - Street 1:1516 WASHINGTON AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2215
Practice Address - Country:US
Practice Address - Phone:319-365-9830
Practice Address - Fax:319-365-9860
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0433516Medicaid