Provider Demographics
NPI:1811728504
Name:TINE, VINCENZO (PA-C)
Entity type:Individual
Prefix:
First Name:VINCENZO
Middle Name:
Last Name:TINE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12020 PACIFIC ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-3507
Mailing Address - Country:US
Mailing Address - Phone:866-227-9495
Mailing Address - Fax:
Practice Address - Street 1:1300 37TH ST STE 1
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1900
Practice Address - Country:US
Practice Address - Phone:866-227-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA125756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant