Healthcare Provider Details

I. General information

NPI: 1780105072
Provider Name (Legal Business Name): TANUJA YALAMARTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

800 SPRUCE ST
PHILADELPHIA PA
19107-6130
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6200
  • Fax: 505-609-2259
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT213786
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD2024-0294
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: