Provider Demographics
NPI:1366150153
Name:KINCAID, TYSON WADE
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:WADE
Last Name:KINCAID
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 1:317 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9547
Mailing Address - Country:US
Mailing Address - Phone:304-719-3915
Mailing Address - Fax:
Practice Address - Street 1:345 PRINCE ST STE 1
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4515
Practice Address - Country:US
Practice Address - Phone:304-254-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty