Provider Demographics
NPI:1194554220
Name:FAN, TINGTING
Entity type:Individual
Prefix:
First Name:TINGTING
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 W TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3287
Mailing Address - Country:US
Mailing Address - Phone:909-895-3299
Mailing Address - Fax:
Practice Address - Street 1:2458 E SALEM ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-3888
Practice Address - Country:US
Practice Address - Phone:626-679-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF05240542363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily