Healthcare Provider Details

I. General information

NPI: 1811065253
Provider Name (Legal Business Name): TINA B. MATHEWS RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 WAVERLY DR
AUGUSTA GA
30909-3121
US

IV. Provider business mailing address

426 WAVERLY DR
AUGUSTA GA
30909-3121
US

V. Phone/Fax

Practice location:
  • Phone: 404-290-3675
  • Fax:
Mailing address:
  • Phone: 404-290-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN053784
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code364SP2800X
TaxonomyPerioperative Clinical Nurse Specialist
License NumberRN053784
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: