Provider Demographics
NPI:1659758779
Name:TISDALE, THOMAS (MS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CULLOWHEE
Mailing Address - State:NC
Mailing Address - Zip Code:28723-6862
Mailing Address - Country:US
Mailing Address - Phone:828-545-4911
Mailing Address - Fax:
Practice Address - Street 1:80 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5126
Practice Address - Country:US
Practice Address - Phone:828-586-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer