Provider Demographics
NPI:1841856598
Name:TIDRICK, GREGG (DNP)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:
Last Name:TIDRICK
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2688 E SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1487
Mailing Address - Country:US
Mailing Address - Phone:602-919-7226
Mailing Address - Fax:
Practice Address - Street 1:2000 E SOUTHERN AVE STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7510
Practice Address - Country:US
Practice Address - Phone:480-820-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ227355367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered