Provider Demographics
NPI:1598215022
Name:TANG, NIKKI BORAH (PA-C)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:BORAH
Last Name:TANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BLANCHARD CIR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7850
Mailing Address - Country:US
Mailing Address - Phone:630-653-0848
Mailing Address - Fax:630-653-0988
Practice Address - Street 1:7 BLANCHARD CIR
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-7850
Practice Address - Country:US
Practice Address - Phone:630-653-0848
Practice Address - Fax:630-653-0988
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006035363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920540OtherMEDICARE GROUP
ILF400460219OtherMEDICARE INDIVIDUAL
IL920540OtherMEDICARE GROUP