Provider Demographics
NPI:1336712033
Name:TIDWELL, RYAN SCOTT (APRN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:661 E ALTAMONTE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5102
Mailing Address - Country:US
Mailing Address - Phone:407-831-4040
Mailing Address - Fax:407-260-0281
Practice Address - Street 1:661 E ALTAMONTE DR STE 115
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5102
Practice Address - Country:US
Practice Address - Phone:407-831-4040
Practice Address - Fax:407-260-0281
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL11014417363LF0000X
FLAPRN11014417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily