Provider Demographics
NPI:1962503045
Name:BURGESS, TINA MARIE (ARNP)
Entity Type:Individual
Prefix:PROF
First Name:TINA
Middle Name:MARIE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:790 DUNLAWTON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9279
Practice Address - Country:US
Practice Address - Phone:386-760-1877
Practice Address - Fax:386-760-2791
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1840402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45360OtherMEDICARE GROUP
FL59-3667262OtherTAX ID#
FLQ33860Medicare UPIN
FLU4132ZMedicare PIN