1083901110 NPI number — DR. GRACE L. TSAN O.D.

Table of content: KERRY HARRISON MS,RD,LDN (NPI 1851573232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083901110 NPI number — DR. GRACE L. TSAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TSAN
Provider First Name:
GRACE
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1083901110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 HAWKINS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22314-6200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-508-0556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 SAN PEDRO DR SE
Provider Second Line Business Practice Location Address:
NEW MEXICO VA HEALTH CARE SYSTEM
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87108-5153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-265-1711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2011

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: 152W00000X , with the licence number:  3407ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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