=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114578507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MICHELLE TANNENBAUM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 GRANNY RD UNIT 2
-----------------------------------------------------
City | FARMINGVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11738-2879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-696-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8330 KEW GARDENS RD APT 4K
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11415-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-910-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1164958
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------