Provider Demographics
NPI:1952507881
Name:TAM, CONNIE MING (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:MING
Last Name:TAM
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 1:22110 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3845
Mailing Address - Country:US
Mailing Address - Phone:818-887-5515
Mailing Address - Fax:
Practice Address - Street 1:22110 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3845
Practice Address - Country:US
Practice Address - Phone:818-887-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant