Provider Demographics
NPI:1427242239
Name:MITTERLING, TINA M (PA-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:MITTERLING
Suffix:
Gender:F
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 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTN PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:2367B CYPRESS CIR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8921
Practice Address - Country:US
Practice Address - Phone:843-349-1001
Practice Address - Fax:843-349-1008
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1235363AM0700X
OH50.002833363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0595PAMedicaid
OH3025372Medicaid
OH0077981Medicaid
OH3025372Medicaid
OHH021953Medicare PIN
OH0077981Medicaid
OH9284951Medicare PIN
OH9389631Medicare PIN
OHH072820Medicare PIN