1750470696 NPI number — ANNIE TAN MD

Table of content: ANNIE TAN MD (NPI 1750470696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750470696 NPI number — ANNIE TAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAN
Provider First Name:
ANNIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1750470696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11850 BLACKFOOT ST NW
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-721-2100
Provider Business Mailing Address Fax Number:
763-721-2190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11850 BLACKFOOT ST NW
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-721-2100
Provider Business Practice Location Address Fax Number:
763-721-2190
Provider Enumeration Date:
10/11/2006

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: 207VX0201X , with the licence number:  47116 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07-05956 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2368961 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP53303 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 961141050294 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 132945 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 83694-0 . This is a "FAIRVIEW" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 815T5TA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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