Provider Demographics
NPI:1215294129
Name:TAN, NGUYEN
Entity type:Individual
Prefix:
First Name:NGUYEN
Middle Name:
Last Name:TAN
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 1:110 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5105
Mailing Address - Country:US
Mailing Address - Phone:408-857-5718
Mailing Address - Fax:
Practice Address - Street 1:110 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5105
Practice Address - Country:US
Practice Address - Phone:408-857-5718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator