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NPI Code Detail

MEDICARE: TISHA JEAN PA-C

MEDICARE: TISHA JEAN PA-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
1363A00000XPhysician AssistantPA102002MA

General Provider Information

NPI Number : 1558094862
Entity Type Code : Individual
Provider Name (Legal Business Name) : TISHA JEAN PA-C
Provider Business Mailing Address
First Line : 588 LONGMEADOW ST
Second Line :
City : LONGMEADOW
State : MA
Zip : 01106-2212
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 588 LONGMEADOW ST
Second Line :
City : LONGMEADOW
State : MA
Zip : 01106-2212
Country : US
Telephone Number : 413-656-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2022
Last Update Date : 02/09/2026

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Directions to “ TISHA JEAN PA-C” Practice Location

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