Provider Demographics
NPI:1265038780
Name:TAN, PAMELA ISABEL (PTA, LMT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ISABEL
Last Name:TAN
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ISABEL
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:19580 HIGHLAND OAKS DR APT 103
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9621
Mailing Address - Country:US
Mailing Address - Phone:847-373-0921
Mailing Address - Fax:
Practice Address - Street 1:19580 HIGHLAND OAKS DR APT 103
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9621
Practice Address - Country:US
Practice Address - Phone:847-373-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA82366225700000X
FLPTA27199225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist