Basic Information
| Provider Information | |||||||||
| NPI: | 1972998391 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TAN | ||||||||
| FirstName: | TONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028778600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4835 S DURANGO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891478171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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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 | 363A00000X | PA0310 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1972998391 | 05 | NV | MEDICAID |