Provider Demographics
NPI:1578262994
Name:NAN, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:NAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 ADRIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1619
Mailing Address - Country:US
Mailing Address - Phone:510-938-5215
Mailing Address - Fax:
Practice Address - Street 1:1319 ADRIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1619
Practice Address - Country:US
Practice Address - Phone:510-938-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19655171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1116416620OtherKAISER PERMANENTE