Provider Demographics
NPI:1669835211
Name:XU, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:XU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 W SUNSET RD APT 2113
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1913
Mailing Address - Country:US
Mailing Address - Phone:702-824-1510
Mailing Address - Fax:
Practice Address - Street 1:4100 BLUE DIAMOND RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7717
Practice Address - Country:US
Practice Address - Phone:702-824-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
NV922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program