Provider Demographics
NPI:1508829474
Name:TAVER, TATYANA (NP)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:TAVER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3627
Mailing Address - Country:US
Mailing Address - Phone:347-203-5557
Mailing Address - Fax:
Practice Address - Street 1:2195 E 22ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3656
Practice Address - Country:US
Practice Address - Phone:718-648-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340541-1363LG0600X
NYF304104-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02614359Medicaid
NYQ40462Medicare UPIN
NY1030GEN061Medicare PIN