Healthcare Provider Details

I. General information

NPI: 1467187229
Provider Name (Legal Business Name): JEROME PATRICK TINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 JIM FORD RD
JONESBOROUGH TN
37659-3129
US

IV. Provider business mailing address

155 JIM FORD RD
JONESBOROUGH TN
37659-3129
US

V. Phone/Fax

Practice location:
  • Phone: 516-967-0805
  • Fax:
Mailing address:
  • Phone: 516-967-0805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110010539
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5240
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010539
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5240
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: