Provider Demographics
NPI:1871830018
Name:SHADE, TINA LEE (MT)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LEE
Last Name:SHADE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 JFK RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2846
Mailing Address - Country:US
Mailing Address - Phone:563-583-3629
Mailing Address - Fax:
Practice Address - Street 1:2255 JFK RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2846
Practice Address - Country:US
Practice Address - Phone:563-583-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02378174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist