Provider Demographics
NPI:1548418437
Name:FAN, TINA MEI (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MEI
Last Name:FAN
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:MEDICAL STAFF OFFICE T14
Mailing Address - Street 2:STONY BROOK UNIVERSITY HOSPITAL
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-7148
Mailing Address - Country:US
Mailing Address - Phone:631-444-2754
Mailing Address - Fax:631-444-6031
Practice Address - Street 1:MEDICAL STAFF OFFICE T14
Practice Address - Street 2:STONY BROOK UNIVERSITY HOSPITAL
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-7148
Practice Address - Country:US
Practice Address - Phone:631-444-2754
Practice Address - Fax:631-444-6031
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program