Provider Demographics
NPI:1396350807
Name:TAN, CRISTOBAL DE JESUS SR
Entity type:Individual
Prefix:
First Name:CRISTOBAL
Middle Name:DE JESUS
Last Name:TAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-3242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3065
Practice Address - Country:US
Practice Address - Phone:239-285-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician