Provider Demographics
NPI:1528621885
Name:AGOSTINELLI, TINA (PA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:AGOSTINELLI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7539
Mailing Address - Country:US
Mailing Address - Phone:813-908-5253
Mailing Address - Fax:813-355-5895
Practice Address - Street 1:16646 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1400
Practice Address - Country:US
Practice Address - Phone:813-908-5253
Practice Address - Fax:813-355-5895
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPAT9112202363A00000X
390200000X
FLPA9112202363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program