Individual
MACKENZIE R TIDERINGTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A-C
Contact information
Practice address
4160 LITTLE YORK RD STE 10, DAYTON, OH 45414-5803
(937) 415-9100
(937) 415-9191
Mailing address
6551 CENTERVILLE BUSINESS PKWY STE 120, CENTERVILLE, OH 45459-2696
(937) 415-9100
(937) 415-9191
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
50.006159RX
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50.006159RX
OH MEDICAL LICENSE
OH
Enumeration date
09/12/2019
Last updated
12/04/2022
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