Provider Demographics
NPI:1093800310
Name:TAM, SIMOND SIUKI (N/A)
Entity Type:Individual
Prefix:MR
First Name:SIMOND
Middle Name:SIUKI
Last Name:TAM
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 SHAWNEE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-5155
Mailing Address - Country:US
Mailing Address - Phone:914-420-9384
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003161-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical