Healthcare Provider Details

I. General information

NPI: 1235368788
Provider Name (Legal Business Name): KAIHOO TANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5507 DUDLEY BLVD
MCCLELLAN CA
95652-1015
US

IV. Provider business mailing address

15765 CAMINO CODORNIZ
SAN DIEGO CA
92127-5823
US

V. Phone/Fax

Practice location:
  • Phone: 707-816-5884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number19578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: