Provider Demographics
NPI:1679296248
Name:TANYIFOR, PIUS AWANDEM
Entity Type:Individual
Prefix:
First Name:PIUS
Middle Name:AWANDEM
Last Name:TANYIFOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 MACKENZIE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-5031
Mailing Address - Country:US
Mailing Address - Phone:763-291-3169
Mailing Address - Fax:
Practice Address - Street 1:2115 COUNTY ROAD D E STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-5353
Practice Address - Country:US
Practice Address - Phone:651-358-7020
Practice Address - Fax:612-293-6742
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9538363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health