Basic Information
Provider Information | |||||||||
NPI: | 1225296007 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAN | ||||||||
FirstName: | JOEL PETER | ||||||||
MiddleName: | MENDOZA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TAN | ||||||||
OtherFirstName: | JOEL | ||||||||
OtherMiddleName: | PETER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 10452 SILVERDALE WAY NW | ||||||||
Address2: |   | ||||||||
City: | SILVERDALE | ||||||||
State: | WA | ||||||||
PostalCode: | 983839411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603077300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10452 SILVERDALE WAY NW | ||||||||
Address2: |   | ||||||||
City: | SILVERDALE | ||||||||
State: | WA | ||||||||
PostalCode: | 983839411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603077300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2008 | ||||||||
LastUpdateDate: | 05/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301092113 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD60053136 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | MD60553136 | WA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.