Provider Demographics
NPI:1245435528
Name:TAN, SOTHEAVY (MHS)
Entity type:Individual
Prefix:MS
First Name:SOTHEAVY
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2884 SANDERLING DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-1367
Mailing Address - Country:US
Mailing Address - Phone:510-996-6929
Mailing Address - Fax:
Practice Address - Street 1:310 8TH ST
Practice Address - Street 2:201
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-6526
Practice Address - Country:US
Practice Address - Phone:510-869-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator