Provider Demographics
NPI:1598751901
Name:BOUSMAN, TINA M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:M
Last Name:BOUSMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-346-5562
Mailing Address - Fax:708-346-2059
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-346-5562
Practice Address - Fax:708-346-2059
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-002077363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07262Medicare PIN
ILK07263Medicare PIN
ILK07264Medicare PIN
ILQ17532Medicare UPIN