Provider Demographics
NPI:1114151214
Name:EVENSON, TINA E (CFNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:E
Last Name:EVENSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:EILEEN
Other - Last Name:KATNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:439009 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57247-6149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2009001820363L00000X
MNR-130178-2363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner