Healthcare Provider Details

I. General information

NPI: 1073865887
Provider Name (Legal Business Name): NGNAM JULIENNE TASSA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 1ST AVE BERNSTEIN PAVILLION, 6TH FLOOR
NEW YORK NY
10009-1834
US

IV. Provider business mailing address

7250 PARKWAY DR STE 500
HANOVER MD
21076-1343
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-2000
  • Fax:
Mailing address:
  • Phone: 443-949-0814
  • Fax: 443-949-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number015930
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: