Provider Demographics
NPI:1336632298
Name:TAN, SEVERINO M (DPT)
Entity Type:Individual
Prefix:
First Name:SEVERINO
Middle Name:M
Last Name:TAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 33RD ST SW
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-5369
Mailing Address - Country:US
Mailing Address - Phone:903-517-6248
Mailing Address - Fax:903-900-4222
Practice Address - Street 1:1675 NE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-2219
Practice Address - Country:US
Practice Address - Phone:903-782-9922
Practice Address - Fax:903-900-4222
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073997261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy