Provider Demographics
NPI:1568706620
Name:TAN, BRUCE W (PT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:TAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 SW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2044
Mailing Address - Country:US
Mailing Address - Phone:215-870-0498
Mailing Address - Fax:
Practice Address - Street 1:4221 PINE TREE DR FL 2
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140
Practice Address - Country:US
Practice Address - Phone:305-935-9599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist