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General NPI Number Information
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NPI Number | 1558179093
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Entity Type | Individual
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Provider Name | TARA ROSE NIZAMOV PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 12/30/2024
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Last Update Date | 06/08/2025
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Provider Practice Location Address
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Address Line | 12 N 7TH AVE
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City | MOUNT VERNON
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State | NY
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Zip | 10550-2026
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Country | US
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Telephone | 917-557-9895
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Fax |
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Provider Business Mailing Address
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Address Line | 12 N 7TH AVE
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City | MOUNT VERNON
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State | NY
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Zip | 10550-2026
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Country | US
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Telephone | 914-261-7448
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 032848
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License Number State | NY
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