Healthcare Provider Details

I. General information

NPI: 1740676022
Provider Name (Legal Business Name): KATHERINE LAURA TISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 ASHES DR STE 206
WILMINGTON NC
28405-8308
US

IV. Provider business mailing address

PO BOX 603725
CHARLOTTE NC
28260-3725
US

V. Phone/Fax

Practice location:
  • Phone: 910-239-9584
  • Fax: 910-679-4086
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2021-01418
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: