Provider Demographics
NPI:1164892691
Name:TANDON, PRIYANKA B (PA-C)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:B
Last Name:TANDON
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 1:33 BUTTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2010
Mailing Address - Country:US
Mailing Address - Phone:631-871-6611
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-27
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019075-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant