Provider Demographics
NPI:1639589971
Name:GANG, TANISHA
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:GANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-3107
Mailing Address - Country:US
Mailing Address - Phone:518-590-3844
Mailing Address - Fax:
Practice Address - Street 1:356 4TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-3107
Practice Address - Country:US
Practice Address - Phone:518-590-3844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268246164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY268246Medicaid