Healthcare Provider Details

I. General information

NPI: 1407760689
Provider Name (Legal Business Name): ANNA ROSE TANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 S KNOLES DRIVE
FLAGSTAFF AZ
86011-0001
US

IV. Provider business mailing address

6510 E RAFTRIVER ST
MESA AZ
85215-9768
US

V. Phone/Fax

Practice location:
  • Phone: 978-935-3284
  • Fax:
Mailing address:
  • Phone: 978-935-3284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: