Provider Demographics
NPI:1619147618
Name:ANSARI, TAHAYYA A M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TAHAYYA
Middle Name:A M
Last Name:ANSARI
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 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-6262
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:KENNER ARMY HEALTH CLINIC
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-0030
Practice Address - Country:US
Practice Address - Phone:804-734-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001749363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ50347Medicare UPIN