Provider Demographics
NPI:1477992253
Name:TISDALE, JIMMY LEE (APRN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:TISDALE
Suffix:
Gender:M
Credentials:APRN, FNP-C
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Other - First Name:
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Mailing Address - Street 1:7117 W WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5575
Mailing Address - Country:US
Mailing Address - Phone:405-470-1224
Mailing Address - Fax:405-217-0063
Practice Address - Street 1:7117 W WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-5575
Practice Address - Country:US
Practice Address - Phone:405-470-1224
Practice Address - Fax:405-217-0063
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKR80659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200500020AMedicaid
OK200599270AMedicaid
OK200599270AMedicaid