Provider Demographics
NPI:1851674998
Name:TAN, NATALIA HANDRAYANI (PA-C)
Entity Type:Individual
Prefix:
First Name:NATALIA
Middle Name:HANDRAYANI
Last Name:TAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 PENNSYLVANIA AVE STE 890
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2145
Mailing Address - Country:US
Mailing Address - Phone:817-250-4280
Mailing Address - Fax:817-250-4281
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 890
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2145
Practice Address - Country:US
Practice Address - Phone:817-250-4280
Practice Address - Fax:817-250-4281
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07379363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285353305Medicaid
TX285353306Medicaid
TX285353306Medicaid
TX390651YKPWMedicare PIN