Provider Demographics
NPI:1700993698
Name:BEAN, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 TOMAHAWK HWY
Mailing Address - Street 2:
Mailing Address - City:HARRELLS
Mailing Address - State:NC
Mailing Address - Zip Code:28444-9765
Mailing Address - Country:US
Mailing Address - Phone:910-532-4106
Mailing Address - Fax:
Practice Address - Street 1:906 S COLLEGE RD UNIT B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4412
Practice Address - Country:US
Practice Address - Phone:910-508-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004725363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ26048Medicare UPIN