Provider Demographics
NPI:1013438779
Name:TAN, ZACHARY (MD)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:ZETAN
Other - Middle Name:
Other - Last Name:DU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1812 E EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944
Mailing Address - Country:US
Mailing Address - Phone:906-748-3751
Mailing Address - Fax:
Practice Address - Street 1:1812 E EDISON AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944
Practice Address - Country:US
Practice Address - Phone:906-748-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2024-01-24
Deactivation Date:2018-05-07
Deactivation Code:
Reactivation Date:2018-07-19
Provider Licenses
StateLicense IDTaxonomies
WAMD61416339207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2250733Medicaid