Provider Demographics
NPI:1619219912
Name:TILSON, MYRA M (NP)
Entity type:Individual
Prefix:MS
First Name:MYRA
Middle Name:M
Last Name:TILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MYRA
Other - Middle Name:M
Other - Last Name:PIERSON-BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5457 TWIN KNOLLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3296
Mailing Address - Country:US
Mailing Address - Phone:410-861-0740
Mailing Address - Fax:434-225-9723
Practice Address - Street 1:5457 TWIN KNOLLS RD STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3296
Practice Address - Country:US
Practice Address - Phone:410-861-0740
Practice Address - Fax:434-225-9723
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212286363LF0000X
MDAC005810363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD072673700Medicaid