Provider Demographics
NPI:1720374804
Name:TANTCHOU, PIERRETTE LARISSE LAURE (MD)
Entity Type:Individual
Prefix:
First Name:PIERRETTE
Middle Name:LARISSE LAURE
Last Name:TANTCHOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 E CINNAMON WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4536
Mailing Address - Country:US
Mailing Address - Phone:856-283-5489
Mailing Address - Fax:
Practice Address - Street 1:813 FOUNDERS PARK DR E STE 101
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6321
Practice Address - Country:US
Practice Address - Phone:479-463-2333
Practice Address - Fax:479-463-2357
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202222001Medicaid