Provider Demographics
NPI:1417904293
Name:FAWNS, TINA DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:DENISE
Last Name:FAWNS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 HARRODSBURG RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-323-6712
Mailing Address - Fax:859-323-6661
Practice Address - Street 1:2195 HARRODSBURG RD STE 125
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3504
Practice Address - Country:US
Practice Address - Phone:859-323-6371
Practice Address - Fax:859-323-6661
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2619152Medicaid
WV3810003773Medicaid
KY64068117Medicaid
KY0307653Medicare ID - Type Unspecified
KY3400335Medicare ID - Type Unspecified
KY0264259Medicare ID - Type Unspecified
KY0632949Medicare ID - Type Unspecified
OH2619152Medicaid
H91126Medicare UPIN
KY0586624Medicare ID - Type Unspecified
WV3810003773Medicaid