Provider Demographics
NPI:1689442816
Name:TISERA, ELISE (PNP-AC/PC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:TISERA
Suffix:
Gender:F
Credentials:PNP-AC/PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3138 PARK SOUTH STATION BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4455
Mailing Address - Country:US
Mailing Address - Phone:703-973-8755
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD STE 3000
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5019270363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics