Provider Demographics
NPI:1366596272
Name:TADAYON, SIAMAK (PAC)
Entity type:Individual
Prefix:
First Name:SIAMAK
Middle Name:
Last Name:TADAYON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7139 SUTTON PL
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4135
Mailing Address - Country:US
Mailing Address - Phone:646-251-3461
Mailing Address - Fax:
Practice Address - Street 1:1901 FIRST AV.
Practice Address - Street 2:METROPOLITAN HOSPITAL SURGERY DEP.
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-423-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008794-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical