MEDICARE: DR. TANYA J. D'AVANZO PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY635	HI
2	103TC0700X	Clinical Psychologist	PSY635	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22363	OTHER	HI	HMSA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194806315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANYA J. D'AVANZO PH.D.

Provider Business Mailing Address
First Line	:	1123 KOOHOO PL
Second Line	:
City	:	KAILUA
State	:	HI
Zip	:	96734-3276
Country	:	US
Telephone Number	:	808-566-3761
Fax Number	:	808-566-3859

Provider Business Practice Location Address
First Line	:	345 QUEEN ST STE 703
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96813-4718
Country	:	US
Telephone Number	:	808-521-3761
Fax Number	:	800-491-4155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	02/01/2019

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