Provider Demographics
NPI:1598215022
Name:TANG, NIKKI BORAH (PA-C)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:BORAH
Last Name:TANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21660 W FIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-7265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21660 W FIELD PKWY
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010-7265
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61936363A00000X
UT14155593-1206363A00000X
IL085006035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920540OtherMEDICARE GROUP
ILF400460219OtherMEDICARE INDIVIDUAL
IL920540OtherMEDICARE GROUP