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General NPI Number Information
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NPI Number | 1174006522
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Entity Type | Individual
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Provider Name | DONALD GREGORY TISDALE JR. NP
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Gender | Male
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Dates
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Enumeration Date | 09/12/2018
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Last Update Date | 05/26/2021
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Provider Practice Location Address
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Address Line | 10 CANEBRAKE BLVD STE 110-09
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City | FLOWOOD
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State | MS
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Zip | 39232-2211
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Country | US
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Telephone | 769-333-8808
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Fax | 769-333-8809
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Provider Business Mailing Address
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Address Line | 10 CANEBRAKE BLVD STE 110-09
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City | FLOWOOD
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State | MS
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Zip | 39232-2211
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Country | US
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Telephone | 769-333-8808
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Fax | 769-333-8809
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 902899
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License Number State | MS
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