Provider Demographics
NPI:1073022174
Name:CROSSMAN, TARA OLIDEYKA
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:OLIDEYKA
Last Name:CROSSMAN
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 1:16102 JEWEL AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4530
Practice Address - Country:US
Practice Address - Phone:347-256-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program