Healthcare Provider Details

I. General information

NPI: 1598751901
Provider Name (Legal Business Name): TINA M BOUSMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST SUITE 306
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

4400 W 95TH ST SUITE 306
OAK LAWN IL
60453-2654
US

V. Phone/Fax

Practice location:
  • Phone: 708-346-5562
  • Fax: 708-346-2059
Mailing address:
  • Phone: 708-346-5562
  • Fax: 708-346-2059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002077
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: