Healthcare Provider Details

I. General information

NPI: 1700450251
Provider Name (Legal Business Name): NAGHMEH TISHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NAGHMEH VAFAMAND

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 4TH ST
LA GRANDE OR
97850-1906
US

IV. Provider business mailing address

PRISMA HEALTH MEDICAL GROUP FAMILY MEDICINE CENTER 3209 COLONIAL DRIVE
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-3138
  • Fax: 541-975-5120
Mailing address:
  • Phone: 803-434-6113
  • Fax: 803-434-8478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL86608
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO219873
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: