Provider Demographics
NPI:1164661674
Name:TIDWELL, RANDY (APN)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:APN
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 507
Mailing Address - Street 2:421 N BROADWAY
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-0507
Mailing Address - Country:US
Mailing Address - Phone:615-323-1020
Mailing Address - Fax:615-323-1021
Practice Address - Street 1:421 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1750
Practice Address - Country:US
Practice Address - Phone:615-323-1020
Practice Address - Fax:615-323-1021
Is Sole Proprietor?:No
Enumeration Date:2009-02-08
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily