Provider Demographics
NPI:1609215268
Name:TAGAB, EDWIN TOMENIO (RN)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:TOMENIO
Last Name:TAGAB
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 MUSTANG MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-4279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3007 MUSTANG MEADOW LN
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-4279
Practice Address - Country:US
Practice Address - Phone:214-493-3454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX735061163W00000X
CT088709163W00000X
CA838832163W00000X
NVRN75702163W00000X
VT026-0032593163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse