Provider Demographics
NPI:1801840566
Name:TIDWELL, ALLAN P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:P
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 MANATEE AVE W
Mailing Address - Street 2:STE 101
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8624
Mailing Address - Country:US
Mailing Address - Phone:941-748-3065
Mailing Address - Fax:
Practice Address - Street 1:215 E WATER ST
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-8828
Practice Address - Country:US
Practice Address - Phone:570-321-2850
Practice Address - Fax:570-321-2851
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S95427Medicare UPIN
S95427Medicare UPIN