MEDICARE: TINA W MD INC A PROFESSIONAL MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1225747421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TINA W MD INC A PROFESSIONAL MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	425 15TH ST UNIT 3142
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-7311
Country	:	US
Telephone Number	:	917-674-1904
Fax Number	:

Provider Business Practice Location Address
First Line	:	1812 11TH ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6212
Country	:	US
Telephone Number	:	917-674-1904
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TINA WU
Credential	:	MD
Telephone Number	:	917-674-1904

Provider Enumeration Date	:	11/16/2022
Last Update Date	:	12/02/2022

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