Provider Demographics
NPI:1134345580
Name:TAN, GISELLE JOAN (MD)
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:JOAN
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S GEAR AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1679
Mailing Address - Country:US
Mailing Address - Phone:319-768-1000
Mailing Address - Fax:
Practice Address - Street 1:1401 W AGENCY RD
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1643
Practice Address - Country:US
Practice Address - Phone:319-768-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085685207XX0004X
MT12646207XX0004X
IAMD48950207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID14869085Medicare PIN