Basic Information
| Provider Information | |||||||||
| NPI: | 1205446945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAXAMANA | ||||||||
| FirstName: | TRISHA | ||||||||
| MiddleName: | DOMANTAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 EAST 149TH STREET, BRONX | ||||||||
| Address2: | INTERNAL MEDICINE DEPARTMENT, SUITE 8-20, LINCOLN MEDI | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185794739 | ||||||||
| FaxNumber: | 7185794836 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 EAST 149TH STREET | ||||||||
| Address2: | INTERNAL MEDICINE DEPARTMENT, SUITE 8-20, LINCOLN MEDI | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185794739 | ||||||||
| FaxNumber: | 7185794836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2020 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/20/2021 | ||||||||
| NPIReactivationDate: | 02/21/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.