Provider Demographics
NPI:1396360186
Name:GEORGE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 CONVENT RD
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1603
Mailing Address - Country:US
Mailing Address - Phone:845-269-8550
Mailing Address - Fax:
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4812
Practice Address - Country:US
Practice Address - Phone:845-368-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342526-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily