Provider Demographics
NPI:1568865665
Name:TAM, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14202 58TH RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5309
Mailing Address - Country:US
Mailing Address - Phone:646-283-9356
Mailing Address - Fax:
Practice Address - Street 1:14202 58TH RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5309
Practice Address - Country:US
Practice Address - Phone:646-283-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant