Provider Demographics
NPI:1184645731
Name:HUMPHREYS, TATYANA (MD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 GYPSY LN
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-1103
Mailing Address - Country:US
Mailing Address - Phone:484-343-8751
Mailing Address - Fax:610-572-7262
Practice Address - Street 1:306 GYPSY LN
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-1103
Practice Address - Country:US
Practice Address - Phone:484-343-8751
Practice Address - Fax:610-572-7262
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047761L207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7582706Medicaid
PA0016592Medicaid
NJ026190Medicare PIN
NJ7582706Medicaid