=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770932303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE TATAR PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2016
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 389 MERRICK AVE
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-867-5132
-----------------------------------------------------
Fax | 516-867-5519
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 BROADWAY 207
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-598-0009
-----------------------------------------------------
Fax | 631-598-0099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 019324
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------