Healthcare Provider Details

I. General information

NPI: 1578917225
Provider Name (Legal Business Name): MASAKO TIDROW FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 DAKOTA DR
SPRING HILL TN
37174-6195
US

IV. Provider business mailing address

109 DAKOTA DR
SPRING HILL TN
37174-6195
US

V. Phone/Fax

Practice location:
  • Phone: 615-302-2651
  • Fax:
Mailing address:
  • Phone: 615-302-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20693
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: