Provider Demographics
NPI:1659342608
Name:TAJALLE, RAY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:
Last Name:TAJALLE
Suffix:
Gender:M
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 1:117 CAROL LN
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-5139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 2426
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:OKINAWA
Practice Address - Zip Code:AP
Practice Address - Country:JP
Practice Address - Phone:611-737-3995
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPA000046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant