Provider Demographics
NPI:1275096844
Name:TISDAL, ALAN LEE (PT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:LEE
Last Name:TISDAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MCFARLAND BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3371
Mailing Address - Country:US
Mailing Address - Phone:205-333-5351
Mailing Address - Fax:
Practice Address - Street 1:400 MCFARLAND BLVD STE F
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3371
Practice Address - Country:US
Practice Address - Phone:205-333-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPHT3143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist