Basic Information
| Provider Information | |||||||||
| NPI: | 1740676022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | LAURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1017 ASHES DR STE 206 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284058308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102399584 | ||||||||
| FaxNumber: | 9106794086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 2021-01418 | NC | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | NNG327A | 01 | NC | MEDICARE PTAN | OTHER | 1740676022 | 05 | NC | MEDICAID |