Provider Demographics
NPI:1548647910
Name:WANGYAL, TASHI (DO)
Entity type:Individual
Prefix:DR
First Name:TASHI
Middle Name:
Last Name:WANGYAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 FOREST AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-2151
Mailing Address - Country:US
Mailing Address - Phone:516-671-9800
Mailing Address - Fax:516-671-9283
Practice Address - Street 1:480 FOREST AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-2151
Practice Address - Country:US
Practice Address - Phone:516-671-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294369-1207QA0000X, 207QA0505X, 207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1548647910Medicaid