Provider Demographics
NPI:1518623453
Name:TAVANO, MICHAEL (PA-C, RT(R))
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TAVANO
Suffix:
Gender:M
Credentials:PA-C, RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WHITE PLAINS RD STE 100W
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5523
Mailing Address - Country:US
Mailing Address - Phone:646-317-3354
Mailing Address - Fax:
Practice Address - Street 1:155 WHITE PLAINS RD STE 100W
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5523
Practice Address - Country:US
Practice Address - Phone:646-317-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2965222471C3402X
NY027256-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography