Basic Information
| Provider Information | |||||||||
| NPI: | 1558569764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYSON | ||||||||
| FirstName: | PATRICE | ||||||||
| MiddleName: | JENNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257656834 | ||||||||
| FaxNumber: | 2257652054 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257656834 | ||||||||
| FaxNumber: | 2257652054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35090026 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | MD.025783 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 208000000X | MD.025783 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1044121 | 05 | LA | MEDICAID | 000000530761 | 01 | OH | ANTHEM | OTHER | 000000225140 | 01 | OH | UNISON | OTHER | 415048 | 01 | OH | WELLCARE | OTHER | 749095 | 01 | OH | BUCKEYE | OTHER | 2745551 | 05 | OH | MEDICAID | 962065 | 01 | OH | AETNA | OTHER | 03659802 | 05 | MS | MEDICAID | 1021891110001 | 01 | PA | PA MEDICAID | OTHER |