Provider Demographics
NPI:1033681820
Name:QUEZADA, TANAIRI H (PA-C)
Entity Type:Individual
Prefix:
First Name:TANAIRI
Middle Name:H
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 FORT WASHINGTON AVE RM 5-124A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3733
Mailing Address - Country:US
Mailing Address - Phone:516-562-5000
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE RM 5-124A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:484-602-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023065363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical