Provider Demographics
NPI:1790212728
Name:TISDALE, STEPHEN ROBERT (MSPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16925 WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-9021
Mailing Address - Country:US
Mailing Address - Phone:734-368-7025
Mailing Address - Fax:
Practice Address - Street 1:2865 N REYNOLDS RD BLDG A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2100
Practice Address - Country:US
Practice Address - Phone:419-578-7200
Practice Address - Fax:419-537-5600
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008212363A00000X
OH50.008487RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant