Provider Demographics
NPI:1568434520
Name:TINSLEY, AUSTIN R
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:R
Last Name:TINSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 LUCY LEE PKWY
Mailing Address - Street 2:STE A
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-686-1144
Mailing Address - Fax:573-686-3312
Practice Address - Street 1:2400 LUCY LEE PKWY
Practice Address - Street 2:STE A
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-686-1144
Practice Address - Fax:573-686-3312
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34610207Q00000X
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200331452Medicaid
A11202Medicare UPIN
MO990001599Medicare PIN