Provider Demographics
NPI:1356856132
Name:TEDLA, TILKSEW A
Entity Type:Individual
Prefix:
First Name:TILKSEW
Middle Name:A
Last Name:TEDLA
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 1:135 CARMEN LN
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7729
Mailing Address - Country:US
Mailing Address - Phone:805-928-7361
Mailing Address - Fax:
Practice Address - Street 1:3795 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7029
Practice Address - Country:US
Practice Address - Phone:559-412-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135884363LF0000X
GARN274800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty