MEDICARE: TYISHA CHARLES CPT, CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246RP1900X	Phlebotomy Technician	A6S6G2H2	PA

General Provider Information

NPI Number	:	1235973744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYISHA CHARLES CPT, CNA

Provider Business Mailing Address
First Line	:	2290 W OREGON AVE # 1141
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4197
Country	:	US
Telephone Number	:	520-729-2707
Fax Number	:	445-800-8643

Provider Business Practice Location Address
First Line	:	2290 W OREGON AVE # 1141
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4197
Country	:	US
Telephone Number	:	267-971-0372
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2024
Last Update Date	:	12/11/2024

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