Provider Demographics
NPI:1497306989
Name:OLDHOUSER, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:OLDHOUSER
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 1:3498 E PINOT NOIR AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-9257
Mailing Address - Country:US
Mailing Address - Phone:717-855-8413
Mailing Address - Fax:
Practice Address - Street 1:3498 E PINOT NOIR AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-9257
Practice Address - Country:US
Practice Address - Phone:717-855-8413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider