Provider Demographics
NPI:1316207079
Name:TANYI, JOSEPH ABANG
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ABANG
Last Name:TANYI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOSEPH
Other - Middle Name:ABANG
Other - Last Name:TANYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11967 BELTSVILLE DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-4004
Mailing Address - Country:US
Mailing Address - Phone:301-764-4745
Mailing Address - Fax:
Practice Address - Street 1:11967 BELTSVILLE DR
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705
Practice Address - Country:US
Practice Address - Phone:301-765-4745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC620439696164W00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCIVERZON ONEMedicaid