Healthcare Provider Details

I. General information

NPI: 1154774586
Provider Name (Legal Business Name): ROBIN TIDWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11355 S PARKER RD UNIT 103
PARKER CO
80134-7705
US

IV. Provider business mailing address

5102 S LISBON WAY
CENTENNIAL CO
80015-6439
US

V. Phone/Fax

Practice location:
  • Phone: 209-747-2107
  • Fax:
Mailing address:
  • Phone: 425-765-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: