Provider Demographics
NPI:1770116568
Name:CLAIBORNE, TYSON LEE
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:LEE
Last Name:CLAIBORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 MIXON AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-5105
Mailing Address - Country:US
Mailing Address - Phone:865-603-2375
Mailing Address - Fax:
Practice Address - Street 1:4501 MIXON AVE APT 107
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-5105
Practice Address - Country:US
Practice Address - Phone:865-603-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant