Provider Demographics
NPI:1477561785
Name:TISDALE, ELIZABETH HART (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HART
Last Name:TISDALE
Suffix:
Gender:F
Credentials: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:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-213-1500
Mailing Address - Fax:828-651-6570
Practice Address - Street 1:14 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2493
Practice Address - Country:US
Practice Address - Phone:828-252-3366
Practice Address - Fax:828-258-0891
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102591363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCC804C489Medicare PIN
NC2750734Medicare ID - Type Unspecified