Basic Information
| Provider Information | |||||||||
| NPI: | 1821010067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 NEW BERN AVE STE 1100 | ||||||||
| Address2: | WPP - STRUCTURAL HEART | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192325202 | ||||||||
| FaxNumber: | 9192316334 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE STE 1100 | ||||||||
| Address2: | WPP - STRUCTURAL HEART | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192325202 | ||||||||
| FaxNumber: | 9192316334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 200201012 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 200201012 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 2085R0204X | 200201012 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 208G00000X | 200201012 | NC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 131VT | 01 | NC | BCBSNC | OTHER | P00418889 | 01 | NC | MEDICARE RAILROAD | OTHER | 190783 | 01 | NC | MEDCOST | OTHER | 89131VT | 05 | NC | MEDICAID |