| Doctor Name: | MR. LARRY E. TIDYMAN |
| NPI Number: | 1972690345 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 343 |
| Business Practice Address: | 1313 N Cheyenne St Benkelman, NE - 690213074 |
| Business Phone Number: | 3084232151 |
| Business Fax Number: | 3084232217 |
| Mailing Address: | Po Box 710, BENKELMAN |
| State: | NE |
| Postal Code: | 690210710 |
| Phone Number: | 3084232151 |
| Fax Number: | 3084232217 |
| NPI Enumeration Date: | 10/06/2006 |
| NPI Last Update Date: | 09/01/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 343 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NE |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |