Basic Information
| Provider Information | |||||||||
| NPI: | 1215347463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | JENSEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356574400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 454 E MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | HEBER CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840321391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356574400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R0967 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 007623 | AZ | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 11271416-1204 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.