Provider Demographics
NPI:1508384603
Name:TSAGKALIDIS, ANNAH LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNAH
Middle Name:LYNNE
Last Name:TSAGKALIDIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNAH
Other - Middle Name:LYNNE
Other - Last Name:POOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 ROBERT WOOD JOHNSON PL
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1928
Mailing Address - Country:US
Mailing Address - Phone:732-828-3000
Mailing Address - Fax:
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1928
Practice Address - Country:US
Practice Address - Phone:585-473-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06630363A00000X
NY023495-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMM4539308OtherDEA