Provider Demographics
NPI:1033975784
Name:GERWIN, TINA DIANE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:DIANE
Last Name:GERWIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:DIANE
Other - Last Name:DORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1570 PROVENCE RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-0401
Mailing Address - Country:US
Mailing Address - Phone:580-220-4427
Mailing Address - Fax:
Practice Address - Street 1:1570 PROVENCE RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-0401
Practice Address - Country:US
Practice Address - Phone:580-220-4427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK216494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily