Provider Demographics
NPI:1255484390
Name:MIEDICO, TANIA MORALES (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:MORALES
Last Name:MIEDICO
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-243-8500
Mailing Address - Fax:
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-243-8500
Practice Address - Fax:702-560-2928
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000320600Medicaid
NV1255484390Medicaid
NVCX4402OtherMEDICARE SMA
FL92196OtherBCBS
NV1255484390OtherMEDICAID SMA
NV13380OtherNV STATE LICENSE
NV1255484390Medicaid
NV13380OtherNV STATE LICENSE
FL000320600Medicaid
FLAE909XMedicare PIN