Provider Demographics
NPI:1972018513
Name:LUMBANGAOL, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LUMBANGAOL
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 1:6768 WINTER NIGHT CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6768 WINTER NIGHT CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1417
Practice Address - Country:US
Practice Address - Phone:909-782-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPA115363A00000X
CAPA55197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty