Healthcare Provider Details

I. General information

NPI: 1164661674
Provider Name (Legal Business Name): RANDY TIDWELL APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2009
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N BROADWAY
PORTLAND TN
37148-1750
US

IV. Provider business mailing address

PO BOX 507 421 N BROADWAY
PORTLAND TN
37148-0507
US

V. Phone/Fax

Practice location:
  • Phone: 615-323-1020
  • Fax: 615-323-1021
Mailing address:
  • Phone: 615-323-1020
  • Fax: 615-323-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13982
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: