Healthcare Provider Details

I. General information

NPI: 1265038780
Provider Name (Legal Business Name): PAMELA ISABEL TAN PTA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAMELA ISABEL TAN P.T.A.

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19580 HIGHLAND OAKS DR APT 103
ESTERO FL
33928-9621
US

IV. Provider business mailing address

19580 HIGHLAND OAKS DR APT 103
ESTERO FL
33928-9621
US

V. Phone/Fax

Practice location:
  • Phone: 847-373-0921
  • Fax:
Mailing address:
  • Phone: 847-373-0921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27199
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA82366
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: