Provider Demographics
NPI:1396939096
Name:TAN, MANUEL PAVIA (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:PAVIA
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8259
Mailing Address - Country:US
Mailing Address - Phone:575-532-8900
Mailing Address - Fax:575-532-8910
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:STE 301
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:575-532-8900
Practice Address - Fax:575-532-8910
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM93164208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF9028Medicaid
B43661Medicare UPIN
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