Healthcare Provider Details

I. General information

NPI: 1134975311
Provider Name (Legal Business Name): JIAYAN TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE, MORENO VALLEY, CA 92555
MORENO VALLEY CA
92555
US

IV. Provider business mailing address

26520 CACTUS AVE, MORENO VALLEY, CA 92555
RIVERSIDE CA
92555
US

V. Phone/Fax

Practice location:
  • Phone: 951-480-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: