Provider Demographics
NPI:1417061870
Name:TANKASALI, KIMBERLY D (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:TANKASALI
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 1:97 W PARKWAY
Mailing Address - Street 2:C/O EMERGENCY DEPARTMENT
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444-1647
Mailing Address - Country:US
Mailing Address - Phone:973-831-5930
Mailing Address - Fax:
Practice Address - Street 1:97 W PARKWAY
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1647
Practice Address - Country:US
Practice Address - Phone:973-831-5446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010698363AM0700X
NJ25MP00145300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6085L2Medicare ID - Type Unspecified
NYQ60979Medicare UPIN
NJ108443WJ8Medicare PIN
NJ108443Medicare PIN