Provider Demographics
NPI:1053460519
Name:TAN, JOSE (PT)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2833
Mailing Address - Country:US
Mailing Address - Phone:908-653-1776
Mailing Address - Fax:908-653-1779
Practice Address - Street 1:30 S UNION AVE
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2833
Practice Address - Country:US
Practice Address - Phone:908-653-1776
Practice Address - Fax:908-653-1779
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00814100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
025577SE2Medicare ID - Type Unspecified