Provider Demographics
NPI:1326422700
Name:FAWCETT, TINA (AGACNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 S WHITE MOUNTAIN RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7827
Mailing Address - Country:US
Mailing Address - Phone:928-537-6700
Mailing Address - Fax:928-532-2118
Practice Address - Street 1:4951 S WHITE MOUNTAIN RD BLDG A
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7827
Practice Address - Country:US
Practice Address - Phone:928-537-6700
Practice Address - Fax:928-532-2118
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354619-4405363L00000X
AZAP8563363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP8563OtherARIZONA LICENSE
UT354619-4405OtherUTAH LICENSE