Provider Demographics
NPI:1740338490
Name:BURT, TINA L (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:BURT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR
Practice Address - Street 2:SUITE 301
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8301
Practice Address - Country:US
Practice Address - Phone:607-739-0352
Practice Address - Fax:607-739-6909
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF300557-1363LA2200X
NY307665-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01276246Medicaid
NY01276246Medicaid