Basic Information
Provider Information | |||||||||
NPI: | 1619217288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THAN | ||||||||
FirstName: | NHAT TAN | ||||||||
MiddleName: | HOANG | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THAN | ||||||||
OtherFirstName: | TAN | ||||||||
OtherMiddleName: | HOANG | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 400 N PEPPER AVE | ||||||||
Address2: |   | ||||||||
City: | COLTON | ||||||||
State: | CA | ||||||||
PostalCode: | 923241801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095801862 | ||||||||
FaxNumber: | 9095801388 | ||||||||
Practice Location | |||||||||
Address1: | 400 N PEPPER AVE | ||||||||
Address2: |   | ||||||||
City: | COLTON | ||||||||
State: | CA | ||||||||
PostalCode: | 923241801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095801862 | ||||||||
FaxNumber: | 9095801388 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2013 | ||||||||
LastUpdateDate: | 11/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 390200000. | CA | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.