Provider Demographics
NPI:1982628764
Name:TAN, LIZA (PT, DPT, MA)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:PT, DPT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5200
Mailing Address - Country:US
Mailing Address - Phone:718-456-2545
Mailing Address - Fax:
Practice Address - Street 1:6805 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5200
Practice Address - Country:US
Practice Address - Phone:718-456-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184710Medicaid