Provider Demographics
NPI:1720569387
Name:IRVAN, TAMSIE
Entity Type:Individual
Prefix:
First Name:TAMSIE
Middle Name:
Last Name:IRVAN
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 1:4369 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-1820
Mailing Address - Country:US
Mailing Address - Phone:925-825-3594
Mailing Address - Fax:
Practice Address - Street 1:4369 ROSE LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-1820
Practice Address - Country:US
Practice Address - Phone:925-825-3594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid