Provider Demographics
NPI:1134858301
Name:TIDWELL, TONY MAURICE
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:MAURICE
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 DEVONHILL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-4077
Mailing Address - Country:US
Mailing Address - Phone:980-215-3027
Mailing Address - Fax:
Practice Address - Street 1:4503 DEVONHILL LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-4077
Practice Address - Country:US
Practice Address - Phone:980-215-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27832707342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company