Healthcare Provider Details

I. General information

NPI: 1487040739
Provider Name (Legal Business Name): TANEN TYRELL ST. CLAIR - BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 HIGH ST
SANTA CRUZ CA
95064-1099
US

IV. Provider business mailing address

1156 HIGH ST
SANTA CRUZ CA
95064-1099
US

V. Phone/Fax

Practice location:
  • Phone: 831-459-2869
  • Fax:
Mailing address:
  • Phone: 831-459-2869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A17296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: