Provider Demographics
NPI:1558985788
Name:CHA, TANG (LICENSED RN)
Entity Type:Individual
Prefix:
First Name:TANG
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:LICENSED RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12944 NIGHTINGALE ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7030
Mailing Address - Country:US
Mailing Address - Phone:763-710-4981
Mailing Address - Fax:763-710-4990
Practice Address - Street 1:12944 NIGHTINGALE ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-7030
Practice Address - Country:US
Practice Address - Phone:763-710-4981
Practice Address - Fax:763-710-4990
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR184904-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR1849040Medicaid