Provider Demographics
NPI:1740296458
Name:DORES, TINA M (CRNA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:DORES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 N STATE HIGHWAY 161
Mailing Address - Street 2:SUITE 200
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6225 N STATE HIGHWAY 161
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2223
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO430687077013OtherTRICARE
MO919124701Medicaid
MO919124701Medicaid
MO045060091Medicare ID - Type UnspecifiedCPIN