Provider Demographics
NPI:1417957341
Name:VAN TASSELL, VANCE J (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:J
Last Name:VAN TASSELL
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 1:6805 FIVE STAR BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4135
Mailing Address - Country:US
Mailing Address - Phone:916-624-3500
Mailing Address - Fax:916-624-3351
Practice Address - Street 1:6805 FIVE STAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4135
Practice Address - Country:US
Practice Address - Phone:916-624-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73627207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G736270Medicaid
CA00G736270Medicare ID - Type Unspecified
CA00G736270Medicaid