Basic Information
| Provider Information | |||||||||
| NPI: | 1306837109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIEDEMANN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MARCUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2750 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | BELLMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117105720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164092000 | ||||||||
| FaxNumber: | 5164092720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 008301 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.