Provider Demographics
NPI:1104178466
Name:TANJANG, STEPHEN AZEH
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:AZEH
Last Name:TANJANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9216 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5409
Mailing Address - Country:US
Mailing Address - Phone:240-505-0787
Mailing Address - Fax:
Practice Address - Street 1:9216 HOBART ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:MD
Practice Address - Zip Code:20774-5409
Practice Address - Country:US
Practice Address - Phone:240-505-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1005996164W00000X
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide