Provider Demographics
NPI:1316911035
Name:TYSON, MARY AMATO (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AMATO
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
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 15386
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0386
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-470-5345
Practice Address - Fax:919-477-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400191207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10999OtherBLUE CROSS BLUE SHIELD
NC8910999Medicaid
NC10999OtherBLUE CROSS BLUE SHIELD
NC8910999Medicaid