Provider Demographics
NPI:1609386028
Name:CARMONA TAMAYO, VANESSA ELIZABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:ELIZABETH
Last Name:CARMONA TAMAYO
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:123 PINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2124
Mailing Address - Country:US
Mailing Address - Phone:203-909-8832
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS ROAD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-9452
Practice Address - Country:US
Practice Address - Phone:631-444-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12481363A00000X
NY030265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant