Provider Demographics
NPI:1558179093
Name:NIZAMOV, TARA ROSE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ROSE
Last Name:NIZAMOV
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:333 E 241ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1713
Mailing Address - Country:US
Mailing Address - Phone:917-557-9895
Mailing Address - Fax:
Practice Address - Street 1:12 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2026
Practice Address - Country:US
Practice Address - Phone:917-557-9895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant