Healthcare Provider Details

I. General information

NPI: 1124081500
Provider Name (Legal Business Name): TINA L BAULER RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8724 E ROSE ST
MESA AZ
85208-1528
US

IV. Provider business mailing address

PO BOX 52320
MESA AZ
85208-0116
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-2610
  • Fax: 480-545-2373
Mailing address:
  • Phone: 480-545-2610
  • Fax: 480-545-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN079847
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: