Provider Demographics
NPI:1639809817
Name:PHAN, TAN (DC)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 BUFORD DR STE 60
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8703
Mailing Address - Country:US
Mailing Address - Phone:770-614-1009
Mailing Address - Fax:
Practice Address - Street 1:3320 BUFORD DR STE 60
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8703
Practice Address - Country:US
Practice Address - Phone:770-614-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor