Healthcare Provider Details

I. General information

NPI: 1841856598
Provider Name (Legal Business Name): GREGG TIDRICK DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E SOUTHERN AVE STE 102
TEMPE AZ
85282-7510
US

IV. Provider business mailing address

2688 E SANTA ROSA DR
GILBERT AZ
85234-1487
US

V. Phone/Fax

Practice location:
  • Phone: 480-820-9141
  • Fax:
Mailing address:
  • Phone: 602-919-7226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number227355
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: