Provider Demographics
NPI:1285010322
Name:TAN, JONATHAN JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JOSEPH
Last Name:TAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 E JEANETTE LN UNIT 146
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6027
Mailing Address - Country:US
Mailing Address - Phone:516-244-6211
Mailing Address - Fax:
Practice Address - Street 1:751 S WEIR CANYON RD STE 165
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1962
Practice Address - Country:US
Practice Address - Phone:714-453-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY081905363A00000X
CA53159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant