Provider Demographics
NPI:1134314362
Name:WILSON H LUY TAN, MD LTD
Entity Type:Organization
Organization Name:WILSON H LUY TAN, MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:H
Authorized Official - Last Name:LUY TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-887-3460
Mailing Address - Street 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 380
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3053
Mailing Address - Country:US
Mailing Address - Phone:920-887-3460
Mailing Address - Fax:920-887-3491
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 380
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3053
Practice Address - Country:US
Practice Address - Phone:920-887-3460
Practice Address - Fax:920-887-3491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28716-0202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty