Provider Demographics
NPI:1487040739
Name:ST. CLAIR - BROWN, TANEN TYRELL
Entity type:Individual
Prefix:
First Name:TANEN
Middle Name:TYRELL
Last Name:ST. CLAIR - BROWN
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 1:1441 CONSTITUTION BLVD
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-3100
Mailing Address - Country:US
Mailing Address - Phone:831-755-4111
Mailing Address - Fax:773-537-0029
Practice Address - Street 1:1441 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3100
Practice Address - Country:US
Practice Address - Phone:831-755-4111
Practice Address - Fax:773-537-0029
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17296208M00000X
WI80011-21208M00000X
390200000X
IL036146122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487040739Medicaid