Provider Demographics
NPI:1114578507
Name:TANNENBAUM, LISA MICHELLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:TANNENBAUM
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:8330 KEW GARDENS RD APT 4K
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1923
Mailing Address - Country:US
Mailing Address - Phone:410-910-0122
Mailing Address - Fax:
Practice Address - Street 1:100 GRANNY RD UNIT 2
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2879
Practice Address - Country:US
Practice Address - Phone:631-696-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1164958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant