Provider Demographics
NPI:1750860284
Name:TAN, KONDRAD R (MOT)
Entity Type:Individual
Prefix:
First Name:KONDRAD
Middle Name:R
Last Name:TAN
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6575 W TROPICANA AVE APT 1067
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4741
Mailing Address - Country:US
Mailing Address - Phone:818-280-7468
Mailing Address - Fax:
Practice Address - Street 1:4855 BLUE DIAMOND RD STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7602
Practice Address - Country:US
Practice Address - Phone:725-207-3770
Practice Address - Fax:702-505-9020
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV181014225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist