Provider Demographics
NPI:1699887331
Name:TAN, SALLY QUE POA (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:QUE POA
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16804 SHORERUN DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-8431
Mailing Address - Country:US
Mailing Address - Phone:405-359-6640
Mailing Address - Fax:
Practice Address - Street 1:1110 N CLASSEN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6843
Practice Address - Country:US
Practice Address - Phone:405-319-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG38467Medicare UPIN