Healthcare Provider Details

I. General information

NPI: 1104506005
Provider Name (Legal Business Name): TETRIS YLIZAH APOSTOL TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17089 MAIN ST
HESPERIA CA
92345-6075
US

IV. Provider business mailing address

10554 CANNON DR
RANCHO CUCAMONGA CA
91730-0366
US

V. Phone/Fax

Practice location:
  • Phone: 760-956-4123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA209622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: