Provider Demographics
NPI:1851749063
Name:WILCOX, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WILCOX
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 1:120 DUGGAN RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3213
Mailing Address - Country:US
Mailing Address - Phone:650-245-1073
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:650-245-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13411684-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program