Provider Demographics
NPI:1730053430
Name:TAN, JAN RAYNDELL AMPARO (NP)
Entity type:Individual
Prefix:
First Name:JAN RAYNDELL
Middle Name:AMPARO
Last Name:TAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22111 MAIN ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22111 MAIN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3057
Practice Address - Country:US
Practice Address - Phone:310-279-9834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily