Provider Demographics
NPI:1720014657
Name:TAN, LAI WAN (MD)
Entity type:Individual
Prefix:
First Name:LAI
Middle Name:WAN
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 1:2512 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 WHEATON WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3303
Practice Address - Country:US
Practice Address - Phone:360-782-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1918TAOtherREGENCE BLUESHIELD
110216790OtherRAILROAD MEDICARE
144839OtherLABOR & INDUSTRIES
5274746OtherAETNA
WA8277956Medicaid
WA8277956Medicaid
WAGAB18936Medicare PIN
WAGAB18933Medicare PIN
WAGAB18935Medicare PIN
144839OtherLABOR & INDUSTRIES
1918TAOtherREGENCE BLUESHIELD
BC6173152OtherDEA
G86011Medicare UPIN