Provider Demographics
NPI:1174354856
Name:KING, TYSON TERRELL
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:TERRELL
Last Name:KING
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 1:3626 N HALL ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-5105
Mailing Address - Country:US
Mailing Address - Phone:469-232-7969
Mailing Address - Fax:469-402-7562
Practice Address - Street 1:3626 N HALL ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5105
Practice Address - Country:US
Practice Address - Phone:469-232-7969
Practice Address - Fax:469-402-7562
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343900000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)