Provider Demographics
NPI:1558319152
Name:TISDALE, FRANK (NP)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:TISDALE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-455-4200
Mailing Address - Fax:417-455-4314
Practice Address - Street 1:336 S JEFFERSON
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850
Practice Address - Country:US
Practice Address - Phone:417-455-4200
Practice Address - Fax:417-455-4314
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076343363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100049170AMedicaid
MO124503OtherANTHEM
P00248188OtherRR MEDICARE
MO428647325Medicaid
KS100283450BMedicaid
MO804214713Medicare PIN
S39182Medicare UPIN