Basic Information
| Provider Information | |||||||||
| NPI: | 1881140259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARVIN | ||||||||
| FirstName: | TANDRA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRUMEDY | ||||||||
| OtherFirstName: | TANDRA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2510 W DUNLAP AVE | ||||||||
| Address2: | STE 290 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850212737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 W DUNLAP AVE | ||||||||
| Address2: | STE 290 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850212737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2016 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP8943 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LA2100X | AP8943 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.