Provider Demographics
NPI:1821781253
Name:MALDONADO, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16015 POWELLS COVE BLVD APT B204
Mailing Address - Street 2:
Mailing Address - City:BEECHHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1304
Mailing Address - Country:US
Mailing Address - Phone:646-265-7668
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD STE 212
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1122
Practice Address - Country:US
Practice Address - Phone:718-470-4198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349526-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily