Provider Demographics
NPI:1861633224
Name:TAN, GWENDOLYN Q (PT)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:Q
Last Name:TAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15144 82ND ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1777
Mailing Address - Country:US
Mailing Address - Phone:718-738-2550
Mailing Address - Fax:718-738-6644
Practice Address - Street 1:15144 82ND ST
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1777
Practice Address - Country:US
Practice Address - Phone:718-738-2550
Practice Address - Fax:718-738-6644
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024390225100000X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology