Basic Information
| Provider Information | |||||||||
| NPI: | 1518101708 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYATANGA | ||||||||
| FirstName: | NOLYN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6317510506 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 W SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115811011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187324049 | ||||||||
| FaxNumber: | 6317510506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 2015010241 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 03906787 | 05 | NY | MEDICAID |