Basic Information
| Provider Information | |||||||||
| NPI: | 1043753957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAI | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP, MSN, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUEST | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045514 | ||||||||
| FaxNumber: | 5102045515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2016 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95005891 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 95005891 | 01 | CA | STATE MEDICAL LICENSE | OTHER |