Provider Demographics
NPI:1619219581
Name:TINA SNODGRASS DERM, PLLC
Entity Type:Organization
Organization Name:TINA SNODGRASS DERM, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-929-5578
Mailing Address - Street 1:1219 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-8955
Mailing Address - Country:US
Mailing Address - Phone:270-926-0707
Mailing Address - Fax:
Practice Address - Street 1:1219 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8955
Practice Address - Country:US
Practice Address - Phone:270-926-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty