Provider Demographics
NPI:1306048574
Name:TOMCZYK, CARLYE TRISTIN (PNP)
Entity type:Individual
Prefix:
First Name:CARLYE
Middle Name:TRISTIN
Last Name:TOMCZYK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:CARLYE
Other - Middle Name:TRISTIN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:10950 UTAH AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1404
Practice Address - Country:US
Practice Address - Phone:612-365-6777
Practice Address - Fax:612-365-8001
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1581379363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics