Provider Demographics
NPI:1477032621
Name:TAN, KINGSLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 FORTIN ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-1957
Mailing Address - Country:US
Mailing Address - Phone:626-290-7539
Mailing Address - Fax:
Practice Address - Street 1:4829 FORTIN ST
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-1957
Practice Address - Country:US
Practice Address - Phone:626-290-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant