Provider Demographics
NPI:1235973744
Name:CHARLES, TYISHA (CPT, CNA)
Entity type:Individual
Prefix:
First Name:TYISHA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:CPT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 W OREGON AVE # 1141
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4197
Mailing Address - Country:US
Mailing Address - Phone:520-729-2707
Mailing Address - Fax:445-800-8643
Practice Address - Street 1:2290 W OREGON AVE # 1141
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4197
Practice Address - Country:US
Practice Address - Phone:267-971-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAA6S6G2H2246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy