Provider Demographics
NPI:1760443154
Name:TAN, SALLY S (MD)
Entity Type:Individual
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First Name:SALLY
Middle Name:S
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1401 N HIGHWAY 89
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2745
Mailing Address - Country:US
Mailing Address - Phone:801-451-4538
Mailing Address - Fax:801-451-2295
Practice Address - Street 1:1401 N HIGHWAY 89
Practice Address - Street 2:SUITE 220
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2745
Practice Address - Country:US
Practice Address - Phone:801-451-4538
Practice Address - Fax:801-451-2295
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
UT363194-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH30124Medicare UPIN