Provider Demographics
NPI:1851176150
Name:TYSON, ERICA (PA-C)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 ROSEGOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-5943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE STE 300
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4246
Practice Address - Country:US
Practice Address - Phone:714-332-5503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-05-16
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