1356830137 NPI number — SHIN HAN JUDY TAM

Table of content: SHIN HAN JUDY TAM (NPI 1356830137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356830137 NPI number — SHIN HAN JUDY TAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAM
Provider First Name:
SHIN HAN JUDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAM
Provider Other First Name:
JUDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356830137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/04/2023
NPI Reactivation Date:
06/19/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17192 MURPHY AVE, PO BOX 14115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-732-8394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17911 SKY PARK CIR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92614-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-202-0257
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2018

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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