Provider Demographics
NPI:1295215523
Name:FUNG, TYLER TAN (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:TAN
Last Name:FUNG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BEACH LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-4002
Mailing Address - Country:US
Mailing Address - Phone:203-239-6878
Mailing Address - Fax:
Practice Address - Street 1:19 BEACH LN
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-4002
Practice Address - Country:US
Practice Address - Phone:203-239-6878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant