Provider Demographics
NPI:1154123388
Name:TAN, KEZIAH ELLERY LAMEYRA (MD)
Entity type:Individual
Prefix:
First Name:KEZIAH ELLERY
Middle Name:LAMEYRA
Last Name:TAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W TOWN AND COUNTRY RD UNIT 446
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-5622
Mailing Address - Country:US
Mailing Address - Phone:714-716-6427
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S STE 400
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program