Provider Demographics
NPI:1457700395
Name:LORRAINE TANGEN M.D. PLLC
Entity Type:Organization
Organization Name:LORRAINE TANGEN M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TANGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-324-6656
Mailing Address - Street 1:1100 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1856
Mailing Address - Country:US
Mailing Address - Phone:208-324-4825
Mailing Address - Fax:
Practice Address - Street 1:1100 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1856
Practice Address - Country:US
Practice Address - Phone:208-324-6656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM 6344261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center