Provider Demographics
NPI:1255428306
Name:TANIEGRA, EDNA (MD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:TANIEGRA
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 1:10725 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7967
Mailing Address - Country:US
Mailing Address - Phone:916-631-3040
Mailing Address - Fax:916-614-4299
Practice Address - Street 1:10725 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-7967
Practice Address - Country:US
Practice Address - Phone:916-631-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1490207Q00000X
CAA56152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131710001Medicaid
G39141Medicare UPIN