Provider Demographics
NPI:1063700888
Name:TYRA, PATRICIA A (RN/PC,PMHCNS-BC)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:TYRA
Suffix:
Gender:F
Credentials:RN/PC,PMHCNS-BC
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 369
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0369
Mailing Address - Country:US
Mailing Address - Phone:508-693-7900
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN ROAD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-693-7900
Practice Address - Fax:508-696-0401
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN83437364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health