Provider Demographics
NPI:1215530316
Name:TUYAHOV, NICOLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TUYAHOV
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SAXTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-4017
Mailing Address - Country:US
Mailing Address - Phone:732-804-0661
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-316-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant