Provider Demographics
NPI:1114577103
Name:TIDERINGTON, MACKENZIE R (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:R
Last Name:TIDERINGTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:R
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6551 CENTERVILLE BUSINESS PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2696
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD STE 10
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5803
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006159RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.006159RXOtherOH MEDICAL LICENSE