Provider Demographics
NPI:1457553885
Name:TANNENBAUM, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 SCENIC DR
Mailing Address - Street 2:APT 107
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4947
Mailing Address - Country:US
Mailing Address - Phone:510-409-8966
Mailing Address - Fax:
Practice Address - Street 1:1808 SCENIC DR
Practice Address - Street 2:APT 107
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:510-409-8966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00697373Medicare PIN
ORR144701Medicare PIN