Provider Demographics
NPI:1275259939
Name:TDT MEDICAL LLC
Entity Type:Organization
Organization Name:TDT MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERBY-TALBOT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:949-588-2190
Mailing Address - Street 1:5 HOLLAND STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2568
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:949-588-2199
Practice Address - Street 1:1801 N CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-1216
Practice Address - Country:US
Practice Address - Phone:775-882-1441
Practice Address - Fax:775-882-6844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty