1114578507 NPI number — MS. LISA MICHELLE TANNENBAUM PA-C

Table of content: DR. SCOTT A JENSEN O.D. (NPI 1780683920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114578507 NPI number — MS. LISA MICHELLE TANNENBAUM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNENBAUM
Provider First Name:
LISA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114578507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8330 KEW GARDENS RD APT 4K
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEW GARDENS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11415-1923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-910-0122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GRANNY RD UNIT 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11738-2879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-696-4357
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1164958 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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