MEDICARE: IESHA TICKNOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	PTL15246	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	390200000X	Student in an Organized Health Care Education/Training Program		CA

General Provider Information

NPI Number	:	1134743198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IESHA TICKNOR

Provider Business Mailing Address
First Line	:	1701 DIVISADERO ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3011
Country	:	US
Telephone Number	:	415-353-7800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 DIVISADERO ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3011
Country	:	US
Telephone Number	:	415-353-7800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2020
Last Update Date	:	04/21/2026

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Directions to “ IESHA TICKNOR ” Practice Location

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