Provider Demographics
NPI:1346327392
Name:DEGROOT, TINA MARIE (APNP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1569
Mailing Address - Country:US
Mailing Address - Phone:608-324-2000
Mailing Address - Fax:920-965-7412
Practice Address - Street 1:515 22ND AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1569
Practice Address - Country:US
Practice Address - Phone:608-324-2000
Practice Address - Fax:920-965-7412
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI358909364SN0000X
WI3554-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38219400Medicaid
P34185Medicare UPIN
WI000207850Medicare ID - Type Unspecified