Provider Demographics
NPI:1992908511
Name:GEARHART, TINA M (CNM)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:GEARHART
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 OLSON RD
Mailing Address - Street 2:
Mailing Address - City:PALOUSE
Mailing Address - State:WA
Mailing Address - Zip Code:99161-9773
Mailing Address - Country:US
Mailing Address - Phone:206-401-2474
Mailing Address - Fax:
Practice Address - Street 1:425 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-2751
Practice Address - Country:US
Practice Address - Phone:509-330-5539
Practice Address - Fax:509-795-0936
Is Sole Proprietor?:No
Enumeration Date:2007-06-10
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60659377176B00000X, 367A00000X
CORXM-8029367A00000X
OR201603004367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80174019Medicaid
COCO300129Medicare PIN