Healthcare Provider Details

I. General information

NPI: 1336712033
Provider Name (Legal Business Name): RYAN SCOTT TIDWELL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 E ALTAMONTE DR STE 115
ALTAMONTE SPRINGS FL
32701-5102
US

IV. Provider business mailing address

661 E ALTAMONTE DR STE 115
ALTAMONTE SPRINGS FL
32701-5102
US

V. Phone/Fax

Practice location:
  • Phone: 407-831-4040
  • Fax: 407-260-0281
Mailing address:
  • Phone: 407-831-4040
  • Fax: 407-260-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11014417
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11014417
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: