Healthcare Provider Details

I. General information

NPI: 1063559177
Provider Name (Legal Business Name): TANIA M PARISE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MEDICAL GROUP 45 PINE RD
LANGLEY AFB VA
23665-2080
US

IV. Provider business mailing address

1ST MEDICAL GROUP 45 PINE RD
LANGLEY AFB VA
23665-2080
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6963
  • Fax: 757-764-0975
Mailing address:
  • Phone: 757-764-6963
  • Fax: 757-764-0975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberPT 21340
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: