Healthcare Provider Details

I. General information

NPI: 1346782539
Provider Name (Legal Business Name): NICOLE VICTORIA TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2016
Last Update Date: 11/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 LOWELL BLVD
DENVER CO
80204-1545
US

IV. Provider business mailing address

1601 LOWELL BLVD
DENVER CO
80204-1545
US

V. Phone/Fax

Practice location:
  • Phone: 720-508-7314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.0013769
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: