Healthcare Provider Details

I. General information

NPI: 1538381629
Provider Name (Legal Business Name): WING SHAN TAM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 DUBLIN BLVD
DUBLIN CA
94568-3112
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-498-2184
  • Fax:
Mailing address:
  • Phone: 510-498-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number929489
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number949489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: