Provider Demographics
NPI:1669667341
Name:ANTOSY, TANYA D (PA-C)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:D
Last Name:ANTOSY
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 1:100 LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-2000
Mailing Address - Fax:
Practice Address - Street 1:100 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00279900363AM0700X
PAMA053181363AM0700X, 363AM0700X
PAMA05311363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical