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: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3091
MODESTO CA
95353-3091
US

IV. Provider business mailing address

PO BOX 3091
MODESTO CA
95353-3091
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-4575
  • Fax:
Mailing address:
  • Phone: 209-575-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95011063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: