Provider Demographics
NPI:1861453151
Name:NANEVICZ, TANIA MARY (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:MARY
Last Name:NANEVICZ
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-652-8600
Mailing Address - Fax:
Practice Address - Street 1:1501 TROUSDALE DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4506
Practice Address - Country:US
Practice Address - Phone:650-653-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77614207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G63509Medicare UPIN