Provider Demographics
NPI:1013366053
Name:THOMAS, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19742 MACARTHUR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2447
Mailing Address - Country:US
Mailing Address - Phone:949-955-0202
Mailing Address - Fax:949-955-0203
Practice Address - Street 1:19742 MACARTHUR BLVD STE 101
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2447
Practice Address - Country:US
Practice Address - Phone:949-955-0202
Practice Address - Fax:949-955-0203
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002076363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health