Basic Information
| Provider Information | |||||||||
| NPI: | 1720583818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | LUAN | ||||||||
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| Credential: | DO, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 E MOUNT ROYAL AVE APT 504 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212028109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142079701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3200 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190131719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 08/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0300X | OS020328 | PA | N | 2083A0300X | H0087983 | MD | N | 2083P0901X | OS020328 | PA | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2083P0901X | H0087983 | MD | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.