Provider Demographics
NPI:1699841932
Name:CAMPANILE, TINA M (PAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CAMPANILE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3185
Mailing Address - Country:US
Mailing Address - Phone:321-254-6218
Mailing Address - Fax:321-254-6230
Practice Address - Street 1:2080 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:321-254-6218
Practice Address - Fax:321-254-6230
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS46931Medicare UPIN
FLE0088WMedicare ID - Type UnspecifiedMEDICARE