Provider Demographics
NPI:1750014296
Name:TISDALE, MOLLIE ANNE (PAC)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:ANNE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:ANNE
Other - Last Name:TUTHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14755 215TH AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9224
Practice Address - Country:US
Practice Address - Phone:231-796-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant