Provider Demographics
NPI:1669014932
Name:TAN, VICTOR JINGXU
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:JINGXU
Last Name:TAN
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 1:1005 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3629
Mailing Address - Country:US
Mailing Address - Phone:808-259-1866
Mailing Address - Fax:
Practice Address - Street 1:1005 14TH AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3629
Practice Address - Country:US
Practice Address - Phone:808-259-1866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU433171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT3955OtherMASSAGE
HIACU433OtherACUPUNCTURE MASSAGE