Basic Information
| Provider Information | |||||||||
| NPI: | 1881019925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINNICK | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | RAND | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PBT(ASCP), PHD, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5647 US HIGHWAY 26 | ||||||||
| Address2: | |||||||||
| City: | DUBOIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825139607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074552516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5647 US HIGHWAY 26 | ||||||||
| Address2: | |||||||||
| City: | DUBOIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825139607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074552516 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2014 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002413 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LP2300X | 986 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363AM0700X | 986 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 986 | 01 | WY | WY LICENSE NUMBER | OTHER | 1881019925 | 01 | NPI NUMBER | OTHER |