Basic Information
| Provider Information | |||||||||
| NPI: | 1801030739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANN | ||||||||
| FirstName: | LUCIANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROZAS | ||||||||
| OtherFirstName: | LUCIANA | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5100 BURCHETTE RD | ||||||||
| Address2: | UNIT 705 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336471504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548041140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13610 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139772777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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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 | 363AM0700X | PA9104829 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 001182400 | 05 | FL | MEDICAID |