Provider Demographics
NPI:1588760003
Name:TAN, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 S HEDGEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-6601
Mailing Address - Country:US
Mailing Address - Phone:316-844-7309
Mailing Address - Fax:316-747-8028
Practice Address - Street 1:6525 E MAINSGATE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1062
Practice Address - Country:US
Practice Address - Phone:316-844-7309
Practice Address - Fax:316-747-8028
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45942207Q00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200551880DMedicaid
KS178951OtherMEDICARE
KS200551880JMedicaid
KSPTAN 016291004OtherMEDICARE - WPS
KS200551880AMedicaid
KS200551880BMedicaid