Basic Information
| Provider Information | |||||||||
| NPI: | 1629047477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WESLIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 6750 W 52ND AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800023956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208983300 | ||||||||
| FaxNumber: | 7208983333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 04/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 27968 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0213X | 27968 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 01279686 | 05 | CO | MEDICAID | 37680761 | 05 | NM | MEDICAID |