Provider Demographics
NPI:1861136145
Name:BARDASH, TALIA
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:BARDASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2243
Mailing Address - Country:US
Mailing Address - Phone:201-446-5507
Mailing Address - Fax:
Practice Address - Street 1:728 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW SQUARE
Practice Address - State:NY
Practice Address - Zip Code:10977-8916
Practice Address - Country:US
Practice Address - Phone:845-354-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028280363A00000X
NJ25MP00701000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant