Provider Demographics
NPI:1336224203
Name:TAN, BLANCA A (MD)
Entity type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:A
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:120 JOCKEY HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-4157
Mailing Address - Country:US
Mailing Address - Phone:908-687-3725
Mailing Address - Fax:908-686-5258
Practice Address - Street 1:3342 KENNEDY BLVD.
Practice Address - Street 2:
Practice Address - City:JERSEY
Practice Address - State:NJ
Practice Address - Zip Code:07307-4233
Practice Address - Country:US
Practice Address - Phone:201-653-8999
Practice Address - Fax:201-653-4477
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03544400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG35613Medicare UPIN