Basic Information
| Provider Information | |||||||||
| NPI: | 1558319152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISDALE | ||||||||
| FirstName: | FRANK | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174554200 | ||||||||
| FaxNumber: | 4174554314 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 S JEFFERSON | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174554200 | ||||||||
| FaxNumber: | 4174554314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 076343 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100049170A | 05 | OK | MEDICAID | 124503 | 01 | MO | ANTHEM | OTHER | P00248188 | 01 | RR MEDICARE | OTHER | 428647325 | 05 | MO | MEDICAID | 100283450B | 05 | KS | MEDICAID |