Provider Demographics
NPI:1164161766
Name:TIDABACK, SHEA HOLBROOK
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:HOLBROOK
Last Name:TIDABACK
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 1:4949 N GOLD AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-1814
Mailing Address - Country:US
Mailing Address - Phone:520-904-9168
Mailing Address - Fax:
Practice Address - Street 1:4949 N GOLD AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-1814
Practice Address - Country:US
Practice Address - Phone:520-904-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer