Healthcare Provider Details

I. General information

NPI: 1730053430
Provider Name (Legal Business Name): JAN RAYNDELL AMPARO TAN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22111 MAIN ST UNIT 3
CARSON CA
90745-3057
US

IV. Provider business mailing address

22111 MAIN ST UNIT 3
CARSON CA
90745-3057
US

V. Phone/Fax

Practice location:
  • Phone: 310-279-9834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: