Provider Demographics
NPI:1053303669
Name:BECKER, TANYA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:JEAN
Last Name:BECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PROSPECT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4482
Mailing Address - Country:US
Mailing Address - Phone:401-728-9206
Mailing Address - Fax:401-722-6960
Practice Address - Street 1:126 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4429
Practice Address - Country:US
Practice Address - Phone:401-728-9206
Practice Address - Fax:401-722-6960
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10708208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RITB55273Medicaid
H49131Medicare UPIN