Provider Demographics
NPI:1346533189
Name:TAN, VICTORIA JAYNE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JAYNE
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:JAYNE
Other - Last Name:WINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:291 E CENTER ST
Mailing Address - Street 2:WEST BRIDGEWATER
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1813
Mailing Address - Country:US
Mailing Address - Phone:508-584-1234
Mailing Address - Fax:508-584-0230
Practice Address - Street 1:291 E CENTER ST
Practice Address - Street 2:WEST BRIDGEWATER
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1813
Practice Address - Country:US
Practice Address - Phone:508-584-1234
Practice Address - Fax:508-584-0230
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258583208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics