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General NPI Number Information
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NPI Number | 1609386028
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Entity Type | Individual
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Provider Name | VANESSA ELIZABETH CARMONA TAMAYO PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/11/2017
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 101 NICOLLS ROAD
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City | STONY BROOK
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State | NY
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Zip | 11794-9452
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Country | US
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Telephone | 631-444-2599
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Fax |
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Provider Business Mailing Address
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Address Line | 123 PINE HILL RD
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2124
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Country | US
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Telephone | 203-909-8832
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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 | 12481
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 030265
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License Number State | NY
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