Provider Demographics
NPI:1457724072
Name:KNEZEVIC, TINA M (PAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:KNEZEVIC
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:DUDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:13991 W GRAND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3065
Mailing Address - Country:US
Mailing Address - Phone:800-233-3264
Mailing Address - Fax:
Practice Address - Street 1:13991 W GRAND AVE STE 105
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3065
Practice Address - Country:US
Practice Address - Phone:800-233-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6217363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical