Provider Demographics
NPI:1073918306
Name:TANYIDAH, NOSTA
Entity Type:Individual
Prefix:
First Name:NOSTA
Middle Name:
Last Name:TANYIDAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7813 MANDAN RD
Mailing Address - Street 2:T2
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7813 MANDAN RD
Practice Address - Street 2:T2
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2139
Practice Address - Country:US
Practice Address - Phone:202-391-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10348305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service