Provider Demographics
NPI:1669683926
Name:SAN JUAN, ZINNIA TAN (MD)
Entity type:Individual
Prefix:
First Name:ZINNIA
Middle Name:TAN
Last Name:SAN JUAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 CHERRY AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4201
Mailing Address - Country:US
Mailing Address - Phone:360-405-7900
Mailing Address - Fax:
Practice Address - Street 1:2601 CHERRY AVE STE 315
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4201
Practice Address - Country:US
Practice Address - Phone:360-405-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9500742-1205207RE0101X
WAMD60837291207RE0101X
TXN8982207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2103643Medicaid