Provider Demographics
NPI:1457671380
Name:TIDMORE, PAUL TIMOTHY (NP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:TIMOTHY
Last Name:TIDMORE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:460 MEDICAL PARK DR STE 106
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5782
Mailing Address - Country:US
Mailing Address - Phone:865-988-4452
Mailing Address - Fax:865-988-6293
Practice Address - Street 1:2210 SUTHERLAND AVE STE 110
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-2337
Practice Address - Country:US
Practice Address - Phone:865-525-4333
Practice Address - Fax:865-374-2203
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14982363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523332Medicaid