Basic Information
| Provider Information | |||||||||
| NPI: | 1649861345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | PAYTON | ||||||||
| MiddleName: | MACKENZIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CRIDER | ||||||||
| OtherFirstName: | PAYTON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17 CAMP RAVINE TRL | ||||||||
| Address2: | |||||||||
| City: | BURNS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370295051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157079076 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3441 DICKERSON PIKE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372072539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157692000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.