Provider Demographics
NPI:1578719894
Name:MYERS, TINA MARIE (NA)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:MYERS
Suffix:
Gender:F
Credentials:NA
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS ED
Mailing Address - Street 1:1211 TRANSIT RD
Mailing Address - Street 2:1211 TRANSIT RD.
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1481
Mailing Address - Country:US
Mailing Address - Phone:716-662-1242
Mailing Address - Fax:716-662-1242
Practice Address - Street 1:1211 TRANSIT RD
Practice Address - Street 2:1211 TRANSIT AVE.
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1481
Practice Address - Country:US
Practice Address - Phone:716-662-1242
Practice Address - Fax:716-662-1242
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA171W00000X
NYNA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor