Provider Demographics
NPI:1447786587
Name:SENEEWONG, TANA
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:
Last Name:SENEEWONG
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 1:158 WALKER RANCH PKWY
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-8811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4422
Practice Address - Country:US
Practice Address - Phone:209-576-3528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA164560207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty