Basic Information
| Provider Information | |||||||||
| NPI: | 1588895395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | YU | ||||||||
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| Credential: | ADULT NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104593204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183204466 | ||||||||
| FaxNumber: | 7189913829 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104593204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183204466 | ||||||||
| FaxNumber: | 7189913829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 30305090 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 209007673 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |