Provider Demographics
NPI:1861373532
Name:WILSON, TISHA LIQUE
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:LIQUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90005
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-9005
Mailing Address - Country:US
Mailing Address - Phone:504-385-5751
Mailing Address - Fax:
Practice Address - Street 1:1231 AUSTIN HWY STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4982
Practice Address - Country:US
Practice Address - Phone:504-385-5751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1551189332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies