Healthcare Provider Details

I. General information

NPI: 1306037114
Provider Name (Legal Business Name): TAHIRA ATIYAH WELLMAN M.S., PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

122 QUEENS AVE
ELMONT NY
11003-4339
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2961
  • Fax:
Mailing address:
  • Phone: 917-856-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number011982
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: