Provider Demographics
NPI:1245310044
Name:MOUSSALLY, TINA MARIE (MSPA-C)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:MOUSSALLY
Suffix:
Gender:F
Credentials:MSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 TRUXTUN AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-0633
Mailing Address - Country:US
Mailing Address - Phone:661-322-2206
Mailing Address - Fax:
Practice Address - Street 1:6501 TRUXTUN AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0633
Practice Address - Country:US
Practice Address - Phone:661-322-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17710OtherSTATE LICENSE
CAQ51991Medicare UPIN