Provider Demographics
NPI:1417300112
Name:TAI, CHIN CHENG
Entity Type:Individual
Prefix:
First Name:CHIN CHENG
Middle Name:
Last Name:TAI
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 1:58 OVERTON FARM RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2403
Mailing Address - Country:US
Mailing Address - Phone:917-434-1674
Mailing Address - Fax:860-413-0963
Practice Address - Street 1:220 MAIN ST S STE 207
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2275
Practice Address - Country:US
Practice Address - Phone:860-590-9592
Practice Address - Fax:860-413-0963
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307846363LA2200X
CT9385363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty