Provider Demographics
NPI:1497204002
Name:TIDWELL, LAUREN BLAIR (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:BLAIR
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 MEMORIAL PKWY SW STE 300
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5623
Mailing Address - Country:US
Mailing Address - Phone:256-881-4112
Mailing Address - Fax:
Practice Address - Street 1:2317 MEMORIAL PKWY SW STE 300
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5623
Practice Address - Country:US
Practice Address - Phone:256-881-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1163363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical