Lisa Michelle Tannenbaum, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

1164958 Issued in NY

Practice address

100 Granny Rd Unit 2
Farmingville, NY 11738-2879

Phone

(631) 696-4357

NPI assigned

Sep 26, 2019

Last updated

Sep 26, 2019By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1569456000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1569456000000",
    "number": "1114578507",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8330 KEW GARDENS RD APT 4K",
            "city": "KEW GARDENS",
            "state": "NY",
            "postal_code": "114151923",
            "telephone_number": "410-910-0122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 GRANNY RD UNIT 2",
            "city": "FARMINGVILLE",
            "state": "NY",
            "postal_code": "117382879",
            "telephone_number": "631-696-4357"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TANNENBAUM",
        "first_name": "LISA",
        "middle_name": "MICHELLE",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-09-26",
        "last_updated": "2019-09-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NY",
            "license": "1164958",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Farmingville, NY
• Providers in Farmingville, NY by specialty
• Physician Assistant in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.