Provider Demographics
NPI:1013060284
Name:TAN, PETER B (RPT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:B
Last Name:TAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 SERENO DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2415
Mailing Address - Country:US
Mailing Address - Phone:707-648-3144
Mailing Address - Fax:707-644-0630
Practice Address - Street 1:765 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2415
Practice Address - Country:US
Practice Address - Phone:707-648-3144
Practice Address - Fax:707-644-0630
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist