Healthcare Provider Details

I. General information

NPI: 1689079337
Provider Name (Legal Business Name): DOUGLAS TIDWELL MSN, ARNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 RAND BLVD
SARASOTA FL
34238-5160
US

IV. Provider business mailing address

4435 SPAHN ST
SARASOTA FL
34232-5135
US

V. Phone/Fax

Practice location:
  • Phone: 941-552-7508
  • Fax: 941-552-7605
Mailing address:
  • Phone: 941-726-2082
  • Fax: 941-786-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9326689
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9326689
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: