Healthcare Provider Details

I. General information

NPI: 1033572268
Provider Name (Legal Business Name): TINA MUSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCANTILE LN
UPPER MARLBORO MD
20774-5374
US

IV. Provider business mailing address

150 BERGEN ST
NEWARK NJ
07103-2496
US

V. Phone/Fax

Practice location:
  • Phone: 301-618-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number31621378
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO034918
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberDO034918
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: