Healthcare Provider Details

I. General information

NPI: 1821096686
Provider Name (Legal Business Name): CHARLES GIRARD TISDALE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LINE AVE STE 100
SHREVEPORT LA
71101-4644
US

IV. Provider business mailing address

1500 LINE AVE STE 100
SHREVEPORT LA
71101-4644
US

V. Phone/Fax

Practice location:
  • Phone: 318-635-3052
  • Fax:
Mailing address:
  • Phone: 318-635-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberA10284
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.A10284
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: