Provider Demographics
NPI:1871851469
Name:WOODCOCK, TINA SUE (CRNA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:SUE
Last Name:WOODCOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9804 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-9030
Mailing Address - Country:US
Mailing Address - Phone:270-999-5801
Mailing Address - Fax:
Practice Address - Street 1:9804 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-9030
Practice Address - Country:US
Practice Address - Phone:270-999-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007395367500000X
KY1109033163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100233350Medicaid
KY7100233350Medicaid