Provider Demographics
NPI:1407633357
Name:TAN, MARK VINCENT SYKI
Entity Type:Individual
Prefix:
First Name:MARK VINCENT
Middle Name:SYKI
Last Name:TAN
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 1:2550 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3406
Mailing Address - Country:US
Mailing Address - Phone:626-744-5242
Mailing Address - Fax:
Practice Address - Street 1:238 S RAMPART BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1404
Practice Address - Country:US
Practice Address - Phone:626-684-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker