Provider Demographics
NPI:1295119329
Name:TU, VAN (PAC)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:
Last Name:TU
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 ROOSEVELT DR
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714
Practice Address - Country:US
Practice Address - Phone:516-661-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant