Basic Information
| Provider Information | |||||||||
| NPI: | 1386935500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 01/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 57414-20 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207R00000X | 15555 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 018923 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0101249917 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 57414-20 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207L00000X | 60120 | MN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.