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General NPI Number Information
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NPI Number | 1538848890
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Entity Type | Individual
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Provider Name | NANUKA TSIBADZE
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Gender | Female
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 5501 OLD YORK RD
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City | PHILADELPHIA
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State | PA
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Zip | 19141-3018
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Country | US
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Telephone | 215-456-7890
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Fax |
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Provider Business Mailing Address
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Address Line | 1512 SPRUCE ST APT 1502
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City | PHILADELPHIA
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State | PA
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Zip | 19102-4553
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Country | US
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Telephone | 267-879-7484
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MT228959
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License Number State | PA
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