Basic Information
Provider Information | |||||||||
NPI: | 1417123829 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TISHON | ||||||||
FirstName: | JAYME | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1031 CARE WAY | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224018425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403717600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2150 PENNSYLVANIA AVE NW | ||||||||
Address2: | SUITE 5-411 | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200373201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2027412236 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2008 | ||||||||
LastUpdateDate: | 12/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101251992 | VA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.