Provider Demographics
NPI:1043201114
Name:LOAYZA, TINA MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:LOAYZA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3292
Mailing Address - Country:US
Mailing Address - Phone:805-474-8450
Mailing Address - Fax:805-474-7169
Practice Address - Street 1:877 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3292
Practice Address - Country:US
Practice Address - Phone:805-474-8450
Practice Address - Fax:805-474-7169
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA178245363L00000X
CANP17203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP3832Medicare ID - Type Unspecified
MAP63614Medicare UPIN