Healthcare Provider Details

I. General information

NPI: 1477947679
Provider Name (Legal Business Name): TINA AUDIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13395 N MARANA MAIN ST
MARANA AZ
85653-7008
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-4111
  • Fax: 520-682-3817
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRS2015-0281
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56172
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: