Provider Demographics
NPI:1194366013
Name:GUEDES, TINA (NP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GUEDES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:
Practice Address - Street 1:85 S 5TH W
Practice Address - Street 2:
Practice Address - City:LAVA HOT SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83246
Practice Address - Country:US
Practice Address - Phone:208-776-5202
Practice Address - Fax:844-492-9775
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily