Provider Demographics
NPI:1821783358
Name:CAO, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CAO
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 1:4311 WILSHIRE BLVD STE 419
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3713
Mailing Address - Country:US
Mailing Address - Phone:323-931-4084
Mailing Address - Fax:
Practice Address - Street 1:4311 WILSHIRE BLVD STE 419
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3713
Practice Address - Country:US
Practice Address - Phone:323-931-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020442363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner