Provider Demographics
NPI:1275897894
Name:TAM, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:TAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:YEEMAN
Other - Last Name:CHENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:157 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2319
Mailing Address - Country:US
Mailing Address - Phone:646-515-5157
Mailing Address - Fax:
Practice Address - Street 1:157 FOREST DR
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2319
Practice Address - Country:US
Practice Address - Phone:646-515-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1190378171W00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor