| Doctor Name: | MS. INGRID MARIA TYSON |
| NPI Number: | 1952354839 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MS FNP |
| License Number: | CNP02197 |
| Business Practice Address: | 780 2nd St Se Bandon, OR - 974118354 |
| Business Phone Number: | 5413472529 |
| Business Fax Number: | 5413479196 |
| Mailing Address: | 130 Principe De Paz, SANTA FE |
| State: | NM |
| Postal Code: | 875089211 |
| Phone Number: | 5057805425 |
| Fax Number: | |
| NPI Enumeration Date: | 05/19/2006 |
| NPI Last Update Date: | 11/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | CNP02197 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |