Provider Demographics
NPI:1962102798
Name:MOMIN, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MOMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 W MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-4323
Mailing Address - Country:US
Mailing Address - Phone:832-518-0648
Mailing Address - Fax:
Practice Address - Street 1:2409 FALCON PASS DR STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062-6276
Practice Address - Country:US
Practice Address - Phone:281-461-1111
Practice Address - Fax:281-461-6860
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1130359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program