Provider Demographics
NPI:1639924830
Name:NIEVES-MARTINEZ, TYRONE OMAR
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:OMAR
Last Name:NIEVES-MARTINEZ
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 1:2296 HENDERSON MILL RD NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2774
Mailing Address - Country:US
Mailing Address - Phone:404-474-2301
Mailing Address - Fax:
Practice Address - Street 1:2296 HENDERSON MILL RD NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2774
Practice Address - Country:US
Practice Address - Phone:404-474-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCPA200001967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program