Provider Demographics
NPI:1033748967
Name:NANONGKHAI, TANYA AM
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:AM
Last Name:NANONGKHAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-1466
Mailing Address - Country:US
Mailing Address - Phone:803-531-6900
Mailing Address - Fax:803-531-6907
Practice Address - Street 1:3310 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1468
Practice Address - Country:US
Practice Address - Phone:803-531-6900
Practice Address - Fax:803-531-6907
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61446233208000000X
SC90003208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics