Provider Demographics
NPI:1124010053
Name:TANAKA, MIEKO (AUD)
Entity Type:Individual
Prefix:DR
First Name:MIEKO
Middle Name:
Last Name:TANAKA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5358
Mailing Address - Country:US
Mailing Address - Phone:910-323-9196
Mailing Address - Fax:910-323-9867
Practice Address - Street 1:955 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5358
Practice Address - Country:US
Practice Address - Phone:910-323-9196
Practice Address - Fax:910-323-9867
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4646231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404172Medicaid
NC89569OtherMEDCOST
NC12393OtherBCBS
NC12393OtherBCBS