Provider Demographics
NPI:1942463229
Name:PHAN, OLIVER TAN (MD)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:TAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 FRANCE AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2129
Mailing Address - Country:US
Mailing Address - Phone:763-221-3201
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:763-221-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57455207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology