Provider Demographics
NPI:1811411267
Name:MERMELSTEIN, TAMAR D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TAMAR
Middle Name:D
Last Name:MERMELSTEIN
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 1:1200 E RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3957
Mailing Address - Country:US
Mailing Address - Phone:201-493-1717
Mailing Address - Fax:
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3957
Practice Address - Country:US
Practice Address - Phone:201-493-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021108363AM0700X, 363AS0400X
NJ25MP00469000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical