Basic Information
| Provider Information | |||||||||
| NPI: | 1750470696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | ANNIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11850 BLACKFOOT ST NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637212100 | ||||||||
| FaxNumber: | 7637212190 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT ST NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637212100 | ||||||||
| FaxNumber: | 7637212190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 47116 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 07-05956 | 01 | MN | MEDICA | OTHER | 2368961 | 01 | MN | ARAZ | OTHER | HP53303 | 01 | MN | HEALTHPARTNERS | OTHER | 961141050294 | 01 | MN | PREFERREDONE | OTHER | 132945 | 01 | MN | UCARE | OTHER | 83694-0 | 01 | MN | FAIRVIEW | OTHER | 815T5TA | 01 | MN | BCBS | OTHER |