Individual
MARK R TISDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
10400 75TH STREET, KENOSHA, WI 53142
(262) 948-7045
(262) 948-7331
Mailing address
10400 75TH STREET, KENOSHA, WI 53142
(262) 948-7045
(262) 948-7331
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
897-019
WI
Other
Enumeration date
01/13/2011
Last updated
01/13/2011
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