Provider Demographics
NPI:1073725669
Name:TITLOW, TAD WAYLAND (APN-C)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:WAYLAND
Last Name:TITLOW
Suffix:
Gender:M
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-3133
Mailing Address - Country:US
Mailing Address - Phone:903-392-8259
Mailing Address - Fax:903-392-8013
Practice Address - Street 1:105 NORTH HIGH STREET
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-3133
Practice Address - Country:US
Practice Address - Phone:903-392-8259
Practice Address - Fax:903-392-8013
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX652143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX652143OtherLICENSE