Basic Information
| Provider Information | |||||||||
| NPI: | 1093751091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4390 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897024390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7754457650 | ||||||||
| FaxNumber: | 7758824206 | ||||||||
| Practice Location | |||||||||
| Address1: | 1470 MEDICAL PARKWAY | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897034636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7754457650 | ||||||||
| FaxNumber: | 7758824206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 11880 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 11880 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | CC4954 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 100510311 | 05 | NV | MEDICAID |