Basic Information
| Provider Information | |||||||||
| NPI: | 1306329693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TISON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PA - C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 MILITARY TRAIL SUITE 204 | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617449733 | ||||||||
| FaxNumber: | 5613316143 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 45TH ST | ||||||||
| Address2: | KIMMEL BUILDING | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618445255 | ||||||||
| FaxNumber: | 5618445245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9111468 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.