Provider Demographics
NPI:1568778116
Name:CORDERO, TINA LOUISE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:LOUISE
Last Name:CORDERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:600 N PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-337-5800
Practice Address - Fax:979-277-9074
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1951363A00000X
MI5601003549363A00000X
NE2116363A00000X
TXPA08180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant