Basic Information
| Provider Information | |||||||||
| NPI: | 1134718893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYERS | ||||||||
| FirstName: | TISA | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 NORMANDIE DR | ||||||||
| Address2: | |||||||||
| City: | BONNE TERRE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636289215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737018408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2021 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2021001577 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.