Healthcare Provider Details

I. General information

NPI: 1477569010
Provider Name (Legal Business Name): JONAH O. TAN M.P.T., P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 E LOS ANGELES AVE SUITE 20
SIMI VALLEY CA
93065-3972
US

IV. Provider business mailing address

1687 ERRINGER RD STE 109
SIMI VALLEY CA
93065-6508
US

V. Phone/Fax

Practice location:
  • Phone: 805-581-4266
  • Fax: 805-581-5049
Mailing address:
  • Phone: 805-581-4266
  • Fax: 805-581-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16970
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT24912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: