Provider Demographics
NPI:1043965148
Name:POWELL, TANYA (A-GP-C)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:A-GP-C
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:A-GP-C
Mailing Address - Street 1:242 HACKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1139
Mailing Address - Country:US
Mailing Address - Phone:518-227-4928
Mailing Address - Fax:
Practice Address - Street 1:242 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209-1139
Practice Address - Country:US
Practice Address - Phone:518-227-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310660363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner