Provider Demographics
NPI:1073747515
Name:WANSOM, TANYAPORN (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYAPORN
Middle Name:
Last Name:WANSOM
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 1:6260 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1830 E MONUMENT ST RM 450C
Practice Address - Street 2:DIVISION OF INFECTIOUS DISEASES
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0020
Practice Address - Country:US
Practice Address - Phone:410-502-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2012-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDNOT YET ISSUED207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine