Provider Demographics
NPI:1740601509
Name:TATUM, LAUREN (PA)
Entity Type:Individual
Prefix:MISS
First Name:LAUREN
Middle Name:
Last Name:TATUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12942 BALTIMORE CT
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 W ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2943
Practice Address - Country:US
Practice Address - Phone:626-331-6411
Practice Address - Fax:626-251-1559
Is Sole Proprietor?:No
Enumeration Date:2013-12-21
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical