Doctor Name: | CHARLES GIRARD TISDALE |
NPI Number: | 1821096686 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PA-C |
License Number: | A10284 |
Business Practice Address: | 1500 Line Avenue Ste. 200 Shreveport, LA - 71101 |
Business Phone Number: | 3186295555 |
Business Fax Number: | 3186295556 |
Mailing Address: | 1500 Line Avenue, Ste. 200 SHREVEPORT |
State: | LA |
Postal Code: | 71101 |
Phone Number: | 3186295555 |
Fax Number: | 3186295556 |
NPI Enumeration Date: | 07/14/2005 |
NPI Last Update Date: | 05/26/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AS0400X |
License Number: | A10284 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | LA |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Surgical |
Taxonomy Definition: |