Provider Demographics
NPI:1013028281
Name:ALLENBURG, TINA MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:ALLENBURG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:WEGRZYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4905 W 66TH STREET
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:612-396-0553
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-520-2000
Practice Address - Fax:763-520-2099
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR119816-0363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43995700Medicaid
MN3054977-00Medicaid
WI43995700Medicaid
P25032Medicare UPIN