Provider Demographics
NPI:1669472916
Name:TAN, CHARITY L (NP)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:L
Last Name:TAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 DEVONSHIRE DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5136
Mailing Address - Country:US
Mailing Address - Phone:760-632-5456
Mailing Address - Fax:
Practice Address - Street 1:1011 DEVONSHIRE DR
Practice Address - Street 2:SUITE E
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5136
Practice Address - Country:US
Practice Address - Phone:760-632-5456
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14259363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ16490Medicare UPIN