Healthcare Provider Details

I. General information

NPI: 1326530676
Provider Name (Legal Business Name): TIMOTHY SCOTT TIDWELL II DNP, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 06/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 HEATHFIELD LN
OKLAHOMA CITY OK
73173-7011
US

IV. Provider business mailing address

12221 HEATHFIELD LN
OKLAHOMA CITY OK
73173-7011
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-1648
  • Fax:
Mailing address:
  • Phone: 918-647-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101752
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: