MEDICARE: MR. ALLAN P. TIDWELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9107652	FL

General Provider Information

NPI Number	:	1801840566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLAN P. TIDWELL PA-C

Provider Business Mailing Address
First Line	:	701 MANATEE AVE W
Second Line	:	STE 101
City	:	BRADENTON
State	:	FL
Zip	:	34205-8624
Country	:	US
Telephone Number	:	941-748-3065
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 E WATER ST
Second Line	:
City	:	MUNCY
State	:	PA
Zip	:	17756-8828
Country	:	US
Telephone Number	:	570-321-2850
Fax Number	:	570-321-2851

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/21/2022

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