Provider Demographics
NPI:1467752402
Name:TAN, DAVID JONATHAN (PA-C)
Entity Type:Individual
Prefix:PROF
First Name:DAVID
Middle Name:JONATHAN
Last Name:TAN
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-579-6500
Mailing Address - Fax:630-579-5860
Practice Address - Street 1:2940 ROLLINGRIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4231
Practice Address - Country:US
Practice Address - Phone:630-579-6500
Practice Address - Fax:630-579-5860
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2016-10-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085004064363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL700860029Medicare UPIN