Healthcare Provider Details

I. General information

NPI: 1760617708
Provider Name (Legal Business Name): TYSHAN NISHEL AUSTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5647 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6325
US

IV. Provider business mailing address

2900 CORPORATE WAY DOOR D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 954-276-1616
  • Fax: 954-276-0186
Mailing address:
  • Phone: 954-276-5685
  • Fax: 954-985-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9104993
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: