Healthcare Provider Details

I. General information

NPI: 1699054056
Provider Name (Legal Business Name): TIA OH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIA YANG NP

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

PO BOX 40
SOUTHBRIDGE MA
01550-0040
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-909-7735
Mailing address:
  • Phone: 508-909-7799
  • Fax: 508-909-7750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2264812
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: