Provider Demographics
NPI:1942199526
Name:WALCOTT, TYRONE JERMAINE (NP)
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:JERMAINE
Last Name:WALCOTT
Suffix:
Gender:X
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 AVON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4423
Mailing Address - Country:US
Mailing Address - Phone:910-323-1718
Mailing Address - Fax:
Practice Address - Street 1:2001 WIDEWATERS PKWY # 122
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7324
Practice Address - Country:US
Practice Address - Phone:732-322-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5022573363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology