Provider Demographics
NPI:1053545657
Name:TYREE, HOWARD V (PA-C)
Entity type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:V
Last Name:TYREE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 COPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7059
Mailing Address - Country:US
Mailing Address - Phone:231-946-8970
Mailing Address - Fax:231-932-4118
Practice Address - Street 1:4075 COPPER RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7059
Practice Address - Country:US
Practice Address - Phone:231-946-8970
Practice Address - Fax:231-932-4118
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003680363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN85240014Medicare PIN
MI0N72080Medicare PIN
0N72080Medicare PIN
MIMI1609028Medicare PIN
MIP35997Medicare UPIN
MIP29950028Medicare PIN