Provider Demographics
NPI:1073692521
Name:TANDON, BHAVNA SHALU (DMSC, PA-C)
Entity Type:Individual
Prefix:
First Name:BHAVNA
Middle Name:SHALU
Last Name:TANDON
Suffix:
Gender:F
Credentials:DMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13193 CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4179
Mailing Address - Country:US
Mailing Address - Phone:909-902-9111
Mailing Address - Fax:
Practice Address - Street 1:13193 CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4179
Practice Address - Country:US
Practice Address - Phone:909-902-9111
Practice Address - Fax:909-902-9199
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA18189AMedicare ID - Type UnspecifiedS
CAP00298268Medicare ID - Type UnspecifiedRAIL ROAD
Q63679Medicare UPIN
CAOPA181890Medicare ID - Type UnspecifiedN