Provider Demographics
NPI:1912492554
Name:TIDWELL, STEVEN
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 RYE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6383
Mailing Address - Country:US
Mailing Address - Phone:615-727-2764
Mailing Address - Fax:
Practice Address - Street 1:2536 HIGHWAY 49 E STE 110
Practice Address - Street 2:
Practice Address - City:PLEASANT VIEW
Practice Address - State:TN
Practice Address - Zip Code:37146-7160
Practice Address - Country:US
Practice Address - Phone:615-746-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4042363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant