Basic Information
| Provider Information | |||||||||
| NPI: | 1811233448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYCNER | ||||||||
| FirstName: | SLAWOMIR | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810031411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195464637 | ||||||||
| FaxNumber: | 7195464484 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810031411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195464637 | ||||||||
| FaxNumber: | 7195464484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2012 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APN.0990527-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.