Provider Demographics
NPI:1114109790
Name:TAN, REGINA (PT)
Entity Type:Individual
Prefix:
First Name:REGINA
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 1:16101 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CRESTHILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-8812
Mailing Address - Country:US
Mailing Address - Phone:815-306-1100
Mailing Address - Fax:815-306-1105
Practice Address - Street 1:2320-2324 WEST JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-3758
Practice Address - Fax:815-741-3974
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR03552Medicare PIN