Provider Demographics
NPI:1740574169
Name:TANG, NIKKI DANIELLE YING (MD)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:DANIELLE YING
Last Name:TANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 SISKIYOU BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6462
Mailing Address - Country:US
Mailing Address - Phone:541-200-2777
Mailing Address - Fax:541-214-2575
Practice Address - Street 1:2924 SISKIYOU BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6462
Practice Address - Country:US
Practice Address - Phone:541-200-2777
Practice Address - Fax:541-214-2575
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD195049207N00000X, 207ND0101X
NY2862881207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500766374Medicaid
MD114347600Medicaid