Healthcare Provider Details

I. General information

NPI: 1659758779
Provider Name (Legal Business Name): THOMAS TISDALE MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HEALTHCARE DR
SYLVA NC
28779-5126
US

IV. Provider business mailing address

927 S COUNTRY CLUB DR
CULLOWHEE NC
28723-6862
US

V. Phone/Fax

Practice location:
  • Phone: 828-586-7934
  • Fax:
Mailing address:
  • Phone: 828-545-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1029
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: