Provider Demographics
NPI:1326422700
Name:FAWCETT, TINA (AGACNP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N RIM DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3111
Mailing Address - Country:US
Mailing Address - Phone:928-773-0003
Mailing Address - Fax:928-773-1170
Practice Address - Street 1:1360 N RIM DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3111
Practice Address - Country:US
Practice Address - Phone:928-774-8000
Practice Address - Fax:928-774-0372
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354619-4405363L00000X
AZAP8563363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP8563OtherARIZONA LICENSE
AZ176578Medicaid