Provider Demographics
NPI:1881672350
Name:PEREZ, TANYA MONIQUE (PA)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:MONIQUE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:436 BROADWAY AVE E
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3828
Mailing Address - Country:US
Mailing Address - Phone:315-681-6645
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC/CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN