Basic Information
| Provider Information | |||||||||
| NPI: | 1033763776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORT | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4196 HIGHWAY 62 412 STE A | ||||||||
| Address2: | |||||||||
| City: | HARDY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725428002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8708562107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744646700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184563456 | ||||||||
| FaxNumber: | 8558605341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 83414 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.