Provider Demographics
NPI:1134590110
Name:TAVAG, EMILY KRYSTINE (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:KRYSTINE
Last Name:TAVAG
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:KRYSTINE
Other - Last Name:HORACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:427 38TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 38TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-2514
Practice Address - Country:US
Practice Address - Phone:718-832-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382472363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics