Provider Demographics
NPI:1891295069
Name:OOMMEN, TINCY (PA-C)
Entity Type:Individual
Prefix:
First Name:TINCY
Middle Name:
Last Name:OOMMEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N MICHIGAN AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7605
Mailing Address - Country:US
Mailing Address - Phone:312-263-4625
Mailing Address - Fax:312-263-5029
Practice Address - Street 1:150 N MICHIGAN AVE STE 1200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7605
Practice Address - Country:US
Practice Address - Phone:312-263-4625
Practice Address - Fax:312-263-5029
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008311363AM0700X
IL085.007491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008311OtherLICENSE