Provider Demographics
NPI:1003350935
Name:TAN, ALEXANDER KERWAY (LAC)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:KERWAY
Last Name:TAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E ARROWHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-5101
Mailing Address - Country:US
Mailing Address - Phone:888-336-6991
Mailing Address - Fax:
Practice Address - Street 1:1515 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4923
Practice Address - Country:US
Practice Address - Phone:888-336-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1054171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist