MEDICARE: MR. JIMMY LEE TISDALE APRN, FNP-C

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	363LF0000X	Family Nurse Practitioner	R80659	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477992253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JIMMY LEE TISDALE APRN, FNP-C

Provider Business Mailing Address
First Line	:	7117 W WILSHIRE BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-5575
Country	:	US
Telephone Number	:	405-470-1224
Fax Number	:	405-217-0063

Provider Business Practice Location Address
First Line	:	7117 W WILSHIRE BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-5575
Country	:	US
Telephone Number	:	405-470-1224
Fax Number	:	405-217-0063

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

Provider Enumeration Date	:	06/14/2013
Last Update Date	:	07/31/2025

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