Healthcare Provider Details

I. General information

NPI: 1568918654
Provider Name (Legal Business Name): QUENTIN WAYNE TINGLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 W 3RD ST
BLOOMINGTON IN
47404-4851
US

IV. Provider business mailing address

2520 CASTOR LN
MADISON IN
47250-2496
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3443
  • Fax: 812-353-3442
Mailing address:
  • Phone: 812-599-8186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003646A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: