1306337381 NPI number — MRS. TINA MARIE DICKINSON AGPCNP-BC

Table of content: MRS. TINA MARIE DICKINSON AGPCNP-BC (NPI 1306337381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306337381 NPI number — MRS. TINA MARIE DICKINSON AGPCNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKINSON
Provider First Name:
TINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGPCNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOCK
Provider Other First Name:
TINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306337381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NEWARK WAYNE COMMUNITY HOSPITAL 111 DRIVING PARK AVE
Provider Second Line Business Mailing Address:
BOX 111, EMERGENCY DEPARTMENT
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-359-2847
Provider Business Mailing Address Fax Number:
315-359-2806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 DRIVING PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14513-1090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-359-2847
Provider Business Practice Location Address Fax Number:
315-359-2806
Provider Enumeration Date:
05/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  F308478-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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