Healthcare Provider Details

I. General information

NPI: 1356856132
Provider Name (Legal Business Name): TILKSEW A TEDLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2017
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

135 CARMEN LN
SANTA MARIA CA
93458-7729
US

V. Phone/Fax

Practice location:
  • Phone: 559-412-7149
  • Fax:
Mailing address:
  • Phone: 805-928-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135884
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN274800
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: