Provider Demographics
NPI:1689346645
Name:BUCK, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BUCK
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 1:5355 KUMQUAT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34291-6338
Mailing Address - Country:US
Mailing Address - Phone:848-448-4712
Mailing Address - Fax:
Practice Address - Street 1:5355 KUMQUAT AVE
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34291-6338
Practice Address - Country:US
Practice Address - Phone:848-448-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider