Provider Demographics
NPI:1063240208
Name:ALI, TAMICA LATOYA
Entity type:Individual
Prefix:
First Name:TAMICA
Middle Name:LATOYA
Last Name:ALI
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 1:301 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:315-448-5881
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF355466363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily