Provider Demographics
NPI:1164434387
Name:SOUTHWARD, TINA J (PAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:J
Last Name:SOUTHWARD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:J
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-624-3470
Mailing Address - Fax:575-627-9520
Practice Address - Street 1:75 UNIVERISTY BLVD
Practice Address - Street 2:STE 130
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203
Practice Address - Country:US
Practice Address - Phone:575-624-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-PA10363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R91401Medicare UPIN