Basic Information
| Provider Information | |||||||||
| NPI: | 1669446415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 PHALEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551305302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512547580 | ||||||||
| FaxNumber: | 6512547584 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 PHALEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551305302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512547580 | ||||||||
| FaxNumber: | 6512547584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 44614 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 44614 | MN | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 064221500 | 05 | MN | MEDICAID |