Provider Demographics
NPI:1437709854
Name:EGNER, TINA MARIE (APRN, CNM)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:EGNER
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3772
Mailing Address - Country:US
Mailing Address - Phone:909-890-5511
Mailing Address - Fax:
Practice Address - Street 1:918 W FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3772
Practice Address - Country:US
Practice Address - Phone:909-890-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW236129367A00000X
MNCNM406367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA266540Medicaid