Healthcare Provider Details

I. General information

NPI: 1619777901
Provider Name (Legal Business Name): JACK TANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2025
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 SUNRISE BLVD
GOLD RIVER CA
95670-4344
US

IV. Provider business mailing address

3030 EXPLORER DR
SACRAMENTO CA
95827-2728
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-1867
  • Fax: 844-491-6066
Mailing address:
  • Phone: 916-642-1867
  • Fax: 844-491-6066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: