Provider Demographics
NPI:1154006757
Name:MCMULLEN, TYSON JOHN
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:JOHN
Last Name:MCMULLEN
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 1:1801 MARKET PL SUITE 400
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583
Mailing Address - Country:US
Mailing Address - Phone:925-324-1116
Mailing Address - Fax:
Practice Address - Street 1:1081 MARKET PL STE 400
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4749
Practice Address - Country:US
Practice Address - Phone:925-324-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program