Provider Demographics
NPI:1255960860
Name:TAN, KHEA MARIE
Entity type:Individual
Prefix:
First Name:KHEA
Middle Name:MARIE
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ANDERSON CT
Mailing Address - Street 2:
Mailing Address - City:SAYREVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08872-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WOODRUFF CIRCLE WMB SUITE 51505
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4859
Practice Address - Country:US
Practice Address - Phone:855-366-7989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA102988204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program