Healthcare Provider Details

I. General information

NPI: 1073210704
Provider Name (Legal Business Name): VICTOR TAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100128
GAINESVILLE FL
32610-0128
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-9928
  • Fax: 352-627-4173
Mailing address:
  • Phone: 352-265-9928
  • Fax: 352-627-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120433
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: