Provider Demographics
NPI:1518938810
Name:TAN, JEANETTE (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7806 GATEWAY BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-1806
Mailing Address - Country:US
Mailing Address - Phone:915-592-6868
Mailing Address - Fax:915-592-6889
Practice Address - Street 1:7806 GATEWAY BLVD E
Practice Address - Street 2:SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1806
Practice Address - Country:US
Practice Address - Phone:915-592-6868
Practice Address - Fax:915-592-6889
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE79360Medicare UPIN
TX00Y303Medicare PIN