Provider Demographics
NPI:1477569010
Name:TAN, JONAH O (MPT, PA-C)
Entity Type:Individual
Prefix:
First Name:JONAH
Middle Name:O
Last Name:TAN
Suffix:
Gender:M
Credentials:MPT, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1687 ERRINGER RD
Mailing Address - Street 2:STE 109
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6508
Mailing Address - Country:US
Mailing Address - Phone:805-581-4266
Mailing Address - Fax:805-581-5049
Practice Address - Street 1:3200 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3972
Practice Address - Country:US
Practice Address - Phone:805-581-4266
Practice Address - Fax:805-581-5049
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16970363A00000X
CAPT249122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q07077Medicare UPIN
WPA16970AMedicare PIN