Provider Demographics
NPI:1104620764
Name:AURELUS, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:AURELUS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14211 HOOK CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14211 HOOK CREEK BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3310
Practice Address - Country:US
Practice Address - Phone:347-447-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2819252174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist