Provider Demographics
NPI:1508949934
Name:TAM, JOHNNY (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST.
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4823
Mailing Address - Country:US
Mailing Address - Phone:212-606-1000
Mailing Address - Fax:646-797-8573
Practice Address - Street 1:535 E 70TH ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:646-797-8743
Practice Address - Fax:646-797-8573
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid