MEDICARE: SARAH ELIZABETH TIDWELL

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	363LF0000X	Family Nurse Practitioner	95027903	CA

General Provider Information

NPI Number	:	1942073218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH ELIZABETH TIDWELL

Provider Business Mailing Address
First Line	:	4237 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2801
Country	:	US
Telephone Number	:	562-336-1656
Fax Number	:

Provider Business Practice Location Address
First Line	:	4237 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2801
Country	:	US
Telephone Number	:	562-336-1656
Fax Number	:

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

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	11/19/2024

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