Individual
CHARLES GIRARD TISDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1500 LINE AVE STE 100, SHREVEPORT, LA 71101-4644
(318) 635-3052
Mailing address
1500 LINE AVE STE 100, SHREVEPORT, LA 71101-4644
(318) 635-3052
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
A10284
LA
363AS0400X
Surgical Physician Assistant
Primary
PA.A10284
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1626708
—
LA
Enumeration date
07/14/2005
Last updated
11/24/2025
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