1265787964 NPI number — COLLEEN MARY TANAKA M.S. ED

Table of content: JOHN PHILIP CLEARY MD (NPI 1669056495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265787964 NPI number — COLLEEN MARY TANAKA M.S. ED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANAKA
Provider First Name:
COLLEEN
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S. ED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S. ED
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265787964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 COMMONWEALTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE GROVE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11755-1723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-946-3136
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 HENRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INWOOD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11096-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-239-2182
Provider Business Practice Location Address Fax Number:
516-374-1068
Provider Enumeration Date:
07/18/2012

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: 171M00000X , with the licence number:  1074492 , 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)

  • Identifier: 171M000000X , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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