Provider Demographics
NPI:1760617708
Name:AUSTIN, TYSHAN NISHEL (PA)
Entity Type:Individual
Prefix:MS
First Name:TYSHAN
Middle Name:NISHEL
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:5647 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6325
Practice Address - Country:US
Practice Address - Phone:954-276-1616
Practice Address - Fax:954-276-0186
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9104993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013087100Medicaid