Provider Demographics
NPI:1144269069
Name:PALLIA, TANYA REGINE (PA-C)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:REGINE
Last Name:PALLIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 REVERE CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-3251
Mailing Address - Country:US
Mailing Address - Phone:410-721-1554
Mailing Address - Fax:
Practice Address - Street 1:575 MAIN ST
Practice Address - Street 2:SUITE351
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4343
Practice Address - Country:US
Practice Address - Phone:301-498-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002443363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP63395Medicare UPIN
DC009616D14Medicare PIN