Provider Demographics
NPI:1669446415
Name:TAN, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:401 PHALEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-5302
Mailing Address - Country:US
Mailing Address - Phone:651-254-7580
Mailing Address - Fax:651-254-7584
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7580
Practice Address - Fax:651-254-7584
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2020-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN44614207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN064221500Medicaid