Provider Demographics
NPI:1184113763
Name:TAN, PETER (PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34612 6TH AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8723
Mailing Address - Country:US
Mailing Address - Phone:253-838-8552
Mailing Address - Fax:253-874-6089
Practice Address - Street 1:34612 6TH AVE S STE 300
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8723
Practice Address - Country:US
Practice Address - Phone:253-838-8552
Practice Address - Fax:253-874-6089
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60865343363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2114182Medicaid