Provider Demographics
NPI:1962023754
Name:TISDALE, NICHOLAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5380 S RAINBOW BLVD STE 236
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1879
Mailing Address - Country:US
Mailing Address - Phone:702-778-2204
Mailing Address - Fax:702-688-4371
Practice Address - Street 1:5380 S RAINBOW BLVD STE 236
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1879
Practice Address - Country:US
Practice Address - Phone:702-778-2204
Practice Address - Fax:702-688-4371
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV22993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine