Provider Demographics
NPI:1285699520
Name:TISDALE, THOMPSON W JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:THOMPSON
Middle Name:W
Last Name:TISDALE
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1781 TATE BLVD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4233
Mailing Address - Country:US
Mailing Address - Phone:828-322-3725
Mailing Address - Fax:828-322-2389
Practice Address - Street 1:1781 TATE BLVD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4233
Practice Address - Country:US
Practice Address - Phone:828-322-3725
Practice Address - Fax:828-322-2389
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP08030Medicare UPIN
NC2752875AMedicare ID - Type Unspecified