Healthcare Provider Details

I. General information

NPI: 1750525531
Provider Name (Legal Business Name): BRENDA KARINA TANYI PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA KARINA AYALA

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-808-5411
  • Fax:
Mailing address:
  • Phone: 202-409-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: