Provider Demographics
NPI:1134140403
Name:TANIMAE, LYNDY M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LYNDY
Middle Name:M
Last Name:TANIMAE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 W COHAWKIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1145
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:856-423-0823
Practice Address - Street 1:6601 VENTNOR AVE STE 105
Practice Address - Street 2:
Practice Address - City:VENTNOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08406
Practice Address - Country:US
Practice Address - Phone:609-350-6680
Practice Address - Fax:609-317-4868
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00080800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMT2050576OtherDEA
NJA00032000OtherCDS