Provider Demographics
NPI:1699039594
Name:TAN, KENNETH SHU-WEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SHU-WEN
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 S PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3639
Mailing Address - Country:US
Mailing Address - Phone:573-884-7733
Mailing Address - Fax:573-882-6228
Practice Address - Street 1:3217 S PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3639
Practice Address - Country:US
Practice Address - Phone:573-884-7733
Practice Address - Fax:573-882-6228
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine