Healthcare Provider Details

I. General information

NPI: 1457671380
Provider Name (Legal Business Name): PAUL TIMOTHY TIDMORE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 SUTHERLAND AVE STE 110
KNOXVILLE TN
37919-2337
US

IV. Provider business mailing address

460 MEDICAL PARK DR STE 106
LENOIR CITY TN
37772-5782
US

V. Phone/Fax

Practice location:
  • Phone: 865-525-4333
  • Fax: 865-374-2203
Mailing address:
  • Phone: 865-988-4452
  • Fax: 865-988-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number14982
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: