Provider Demographics
NPI:1821168840
Name:BRANSON, TINA G (PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:G
Last Name:BRANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:GERTRUDE
Other - Last Name:GARAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:945 GOETHALS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3552
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2267
Practice Address - Street 1:945 GOETHALS DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-3627
Practice Address - Fax:509-946-2340
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004535363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436263Medicaid
WA8800956Medicare ID - Type Unspecified
WAQ01166Medicare UPIN