Provider Demographics
NPI:1689079337
Name:TIDWELL, DOUGLAS (MSN, ARNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MSN, ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 SPAHN ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-5135
Mailing Address - Country:US
Mailing Address - Phone:941-726-2082
Mailing Address - Fax:941-786-0960
Practice Address - Street 1:5955 RAND BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-5160
Practice Address - Country:US
Practice Address - Phone:941-552-7508
Practice Address - Fax:941-552-7605
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9326689363LF0000X
FL9326689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIB924ZOtherMEDICARE