Provider Demographics
NPI: | 1508089749 |
---|---|
Name: | TISDALE, AMY (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | AMY |
Middle Name: | |
Last Name: | TISDALE |
Suffix: | |
Gender: | F |
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: | 3115 BRANSFORD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | AUGUSTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30909-3007 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 706-364-8393 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 536 GRAND SLAM DR |
Practice Address - Street 2: | |
Practice Address - City: | EVANS |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30809-8014 |
Practice Address - Country: | US |
Practice Address - Phone: | 706-854-8434 |
Practice Address - Fax: | 706-854-8435 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-04-10 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 006776 | 225100000X, 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
Not Answered | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 006776 | Other | PT LICENSE |