Provider Demographics
NPI:1376805044
Name:VAN TASSEL, DANE (MD)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:VAN TASSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4409
Mailing Address - Country:US
Mailing Address - Phone:602-406-3540
Mailing Address - Fax:
Practice Address - Street 1:2929 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-470-5000
Practice Address - Fax:602-933-1214
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73452207R00000X
AZ481872085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR73452OtherTRAINING PERMIT