Basic Information
| Provider Information | |||||||||
| NPI: | 1073168951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIAPO | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | PAVELA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816800 | ||||||||
| FaxNumber: | 2097253811 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816800 | ||||||||
| FaxNumber: | 2097253811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 37127 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
ID Information
| ID | Type | State | Issuer | Description | 37127 | 05 | CA | MEDICAID |