Healthcare Provider Details

I. General information

NPI: 1124824404
Provider Name (Legal Business Name): JING TAN EMT-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 MEMORIAL DR SE
ATLANTA GA
30316-1185
US

IV. Provider business mailing address

1980 TANGLEWOOD DR
SNELLVILLE GA
30078-3037
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-5773
  • Fax:
Mailing address:
  • Phone: 678-646-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA033724
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: