Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 074484 | IA |
Y | 222Z00000X | Podiatrist | 074484 | IA |
NPI | 1043627292 |
---|---|
Provider Name | Travis Tidwell |
First Address | Cedar Falls, IA 50613-1612 |
Second Address | Waterloo, IA 50702-5620 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2014 |
Last Update Date | 21/09/2017 |