Provider Demographics
NPI:1669768255
Name:YAIBUATHES, TANIMA (NP)
Entity type:Individual
Prefix:MS
First Name:TANIMA
Middle Name:
Last Name:YAIBUATHES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HILLBERRY LN
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2044
Mailing Address - Country:US
Mailing Address - Phone:631-588-5211
Mailing Address - Fax:
Practice Address - Street 1:149 COMMACK RD STE A
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3459
Practice Address - Country:US
Practice Address - Phone:631-462-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305522-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health