Provider Demographics
NPI:1205137981
Name:WAN, TAMMY (MD)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:WAN
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 1:200 UCLA MEDICAL PLZ
Mailing Address - Street 2:SUITE 420
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8344
Mailing Address - Country:US
Mailing Address - Phone:310-206-4083
Mailing Address - Fax:310-206-3551
Practice Address - Street 1:200 UCLA MEDICAL PLZ
Practice Address - Street 2:SUITE 420
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8344
Practice Address - Country:US
Practice Address - Phone:310-206-4083
Practice Address - Fax:310-206-3551
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHG352ZMedicare PIN