Provider Demographics
NPI:1154335354
Name:TKACZEK, TINA MARIE (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:TKACZEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:SCHMUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:2150 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-739-5676
Practice Address - Fax:413-733-5860
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P42136Medicare UPIN
MANP350901Medicare PIN