Provider Demographics
NPI:1235710096
Name:TAN, JOEBERT ABAYGAR
Entity Type:Individual
Prefix:
First Name:JOEBERT
Middle Name:ABAYGAR
Last Name:TAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 STAGG ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-2135
Mailing Address - Country:US
Mailing Address - Phone:818-625-9537
Mailing Address - Fax:
Practice Address - Street 1:10667 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-5931
Practice Address - Country:US
Practice Address - Phone:818-368-9484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist