Basic Information
| Provider Information | |||||||||
| NPI: | 1164410577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393438220 | ||||||||
| FaxNumber: | 2393438221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1569 MATTHEW DR | ||||||||
| Address2: | |||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393438220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP1351842 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | ARNP1351842 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 306957500 | 05 | FL | MEDICAID |