Provider Demographics
NPI:1528447372
Name:TIDWELL, CHRISTINA MICHELLE (PA)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:MICHELLE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:CHRISTINA
Other - Middle Name:MICHELLE
Other - Last Name:DACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-0597
Mailing Address - Country:US
Mailing Address - Phone:912-685-1244
Mailing Address - Fax:
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-535-5555
Practice Address - Fax:912-535-5891
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant