Basic Information
| Provider Information | |||||||||
| NPI: | 1053918441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TETRO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 WHEELER ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124011659 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5353 REYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128196000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2020 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 9992 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.