Provider Demographics
NPI:1588895395
Name:TAN, JENNY YU (ADULT NP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:YU
Last Name:TAN
Suffix:
Gender:F
Credentials:ADULT NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3204
Mailing Address - Country:US
Mailing Address - Phone:718-320-4466
Mailing Address - Fax:718-991-3829
Practice Address - Street 1:975 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3204
Practice Address - Country:US
Practice Address - Phone:718-320-4466
Practice Address - Fax:718-991-3829
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30305090363LA2200X
IL209007673363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331978Medicare Oscar/Certification
NY331944Medicare Oscar/Certification
NY331954Medicare Oscar/Certification
NY331952Medicare Oscar/Certification
NY331947Medicare Oscar/Certification
NY331943Medicare Oscar/Certification
NY331945Medicare Oscar/Certification
NYG10000410Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
NY00695941Medicaid
NY331957Medicare Oscar/Certification
NY331009Medicare Oscar/Certification