Provider Demographics
NPI:1679558530
Name:MCCORKELL, TINA R (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:MCCORKELL
Suffix:
Gender:F
Credentials:FNP
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 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:420 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1024
Practice Address - Country:US
Practice Address - Phone:573-223-4233
Practice Address - Fax:573-223-2136
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110399363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO006013890OtherMEDICARE
MO428829402Medicaid
MOP98541Medicare UPIN