1801873740 NPI number — DR. LEON TAN QUE JR. MD

Table of content: DR. LEON TAN QUE JR. MD (NPI 1801873740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801873740 NPI number — DR. LEON TAN QUE JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUE
Provider First Name:
LEON
Provider Middle Name:
TAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801873740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3445 PENROSE PL
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80301-1878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-442-2288
Provider Business Mailing Address Fax Number:
303-444-5551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3445 PENROSE PL
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80301-1878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-442-2288
Provider Business Practice Location Address Fax Number:
303-444-5551
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  DR-49828 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A83944 . This is a "MEDICAL BOARD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: M67254 . This is a "DIVISION OF DRUG CONTROL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: D68063 . This is a "BOARD OF PHYSICIANS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DR-49828 . This is a "LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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