Basic Information
| Provider Information | |||||||||
| NPI: | 1104824630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TJAN | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704978001 | ||||||||
| FaxNumber: | 9702407793 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704978001 | ||||||||
| FaxNumber: | 9702407793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036026 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 47519 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 18480373 | 05 | CO | MEDICAID | 001360263 | 05 | CT | MEDICAID |