Healthcare Provider Details

I. General information

NPI: 1467882829
Provider Name (Legal Business Name): TINAMARIE DZIENKIEWICZ P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINAMARIE GREGORIO P.A. -C

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 US HIGHWAY 130
HAMILTON NJ
08691-2101
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 609-568-9383
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00323100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: