Provider Demographics
NPI:1588740880
Name:TANKE, SUSAN ROGGEN (CNM, NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ROGGEN
Last Name:TANKE
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PELHAM PARKWAY SOUTH
Mailing Address - Street 2:BUILDING 1 3 WEST 7
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-918-5446
Mailing Address - Fax:718-918-6787
Practice Address - Street 1:1400 PELHAM PARKWAY SOUTH
Practice Address - Street 2:BUILDING 1 3 WEST 7
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-918-5446
Practice Address - Fax:718-918-6787
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000783176B00000X
NYF420555363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02297698Medicaid