Provider Demographics
NPI:1780723007
Name:ONEILL, TINA MARIE (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:ONEILL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-1252
Mailing Address - Country:US
Mailing Address - Phone:315-493-1052
Mailing Address - Fax:
Practice Address - Street 1:117 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1252
Practice Address - Country:US
Practice Address - Phone:315-493-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3005691363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583697Medicaid
NYS28221Medicare UPIN
NY00583697Medicaid