Provider Demographics
NPI:1982985057
Name:PRISTACH-PATRICK, TINA MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:PRISTACH-PATRICK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-682-3817
Practice Address - Street 1:5224 W DOVE CENTRE RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-5063
Practice Address - Country:US
Practice Address - Phone:520-616-1445
Practice Address - Fax:520-616-1446
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4179363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ667808Medicaid