Provider Demographics
NPI:1306168943
Name:TAN, KATIE LE (PA)
Entity type:Individual
Prefix:MISS
First Name:KATIE
Middle Name:LE
Last Name:TAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S SAN VICENTE BLVD # A3100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3311
Mailing Address - Country:US
Mailing Address - Phone:415-315-2341
Mailing Address - Fax:
Practice Address - Street 1:127 S SAN VICENTE BLVD # A3100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3311
Practice Address - Country:US
Practice Address - Phone:424-315-2341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20786363A00000X
CAPA20786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant