Provider Demographics
NPI:1740243492
Name:PERKINS-MWANTUALI, TANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:
Last Name:PERKINS-MWANTUALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 CULVER AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-738-7186
Mailing Address - Fax:315-738-0188
Practice Address - Street 1:1255 CULVER AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501
Practice Address - Country:US
Practice Address - Phone:315-738-7186
Practice Address - Fax:315-738-0188
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215859207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02048988Medicaid
NY02048988Medicaid