Provider Demographics
NPI:1144754979
Name:TANDYASRAYA, PRITA (MD)
Entity Type:Individual
Prefix:
First Name:PRITA
Middle Name:
Last Name:TANDYASRAYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-3244
Mailing Address - Fax:702-653-2378
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-3244
Practice Address - Fax:702-653-2378
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1655582084N0400X
AZR760532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology