Provider Demographics
NPI:1972690345
Name:TIDYMAN, LARRY E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:TIDYMAN
Suffix:
Gender:M
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:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:BENKELMAN
Mailing Address - State:NE
Mailing Address - Zip Code:69021-0710
Mailing Address - Country:US
Mailing Address - Phone:308-423-2151
Mailing Address - Fax:308-423-2217
Practice Address - Street 1:1313 N CHEYENNE ST
Practice Address - Street 2:
Practice Address - City:BENKELMAN
Practice Address - State:NE
Practice Address - Zip Code:69021-3074
Practice Address - Country:US
Practice Address - Phone:308-423-2151
Practice Address - Fax:308-423-2217
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE343363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37814OtherBCBS OF NE
KS2287458901Medicaid
NE37814OtherBCBS OF NE
NEP45619Medicare UPIN
NE970023465Medicare ID - Type UnspecifiedRAILROAD MEDICARE