Basic Information
| Provider Information | |||||||||
| NPI: | 1275654683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAPEN | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 933 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553889271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529553270 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 6960 | MN | Y | Other Service Providers | Specialist |
No ID Information.