Healthcare Provider Details

I. General information

NPI: 1992341606
Provider Name (Legal Business Name): BRIANA TAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MINERAL KING AVE
VISALIA CA
93291-6237
US

IV. Provider business mailing address

393 E WALNUT ST FL 3 PHR GROUP PROVIDER ENROLLMENT UNIT
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 559-624-2213
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: