Provider Demographics
NPI:1598482580
Name:O'BANNER, TYRONE
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:O'BANNER
Suffix:
Gender:
Credentials:
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 6768
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-6768
Mailing Address - Country:US
Mailing Address - Phone:413-218-4888
Mailing Address - Fax:
Practice Address - Street 1:417 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3736
Practice Address - Country:US
Practice Address - Phone:413-301-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAPRN10003790363LP0808X
MARN2345699163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health