Provider Demographics
NPI:1659357929
Name:WIN, TIN T (MD)
Entity Type:Individual
Prefix:
First Name:TIN
Middle Name:T
Last Name:WIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1440
Mailing Address - Country:US
Mailing Address - Phone:928-680-8282
Mailing Address - Fax:928-680-8288
Practice Address - Street 1:2180 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6879
Practice Address - Country:US
Practice Address - Phone:928-680-8282
Practice Address - Fax:928-680-8288
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ77790Medicaid
AZAZ77790Medicaid
AZG01617Medicare UPIN