Provider Demographics
NPI:1689151037
Name:TAN, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 MCKEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4708
Mailing Address - Country:US
Mailing Address - Phone:757-319-2713
Mailing Address - Fax:
Practice Address - Street 1:4417 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2319
Practice Address - Country:US
Practice Address - Phone:231-944-1761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001266487163W00000X
PARN709596163W00000X
PAMW010505367A00000X
PASP019491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife