Provider Demographics
NPI:1336659689
Name:PHAN, TUAN
Entity Type:Individual
Prefix:
First Name:TUAN
Middle Name:
Last Name:PHAN
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 1:11 ESTES ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3057
Mailing Address - Country:US
Mailing Address - Phone:857-222-1710
Mailing Address - Fax:
Practice Address - Street 1:22 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5119
Practice Address - Country:US
Practice Address - Phone:781-851-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAN0114518701OtherTUFTS HEALTH PLAN
MA100042212066OtherMASSHEALTH