Healthcare Provider Details

I. General information

NPI: 1053303669
Provider Name (Legal Business Name): TANYA JEAN BECKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 PROSPECT ST
PAWTUCKET RI
02860-4429
US

IV. Provider business mailing address

59 PROSPECT ST SUITE C
PAWTUCKET RI
02860-4482
US

V. Phone/Fax

Practice location:
  • Phone: 401-728-9206
  • Fax: 401-722-6960
Mailing address:
  • Phone: 401-728-9206
  • Fax: 401-722-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10708
License Number StateRI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierTB55273
Identifier TypeMEDICAID
Identifier StateRI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: