Provider Demographics
NPI:1336103621
Name:TAN, EMILIZA NGO (DPM)
Entity Type:Individual
Prefix:DR
First Name:EMILIZA
Middle Name:NGO
Last Name:TAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 4TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4329
Mailing Address - Country:US
Mailing Address - Phone:707-546-2107
Mailing Address - Fax:707-573-0315
Practice Address - Street 1:1041 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4329
Practice Address - Country:US
Practice Address - Phone:707-546-2107
Practice Address - Fax:707-573-0315
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4045213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5464070001Medicare NSC
CA000E4045Medicare PIN
CAU65894Medicare UPIN