Healthcare Provider Details

I. General information

NPI: 1851827893
Provider Name (Legal Business Name): PEI W TAN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 OLDE TOWNE PKWY STE 150A
MARIETTA GA
30068-4357
US

IV. Provider business mailing address

4800 OLDE TOWNE PKWY STE 150A
MARIETTA GA
30068-4357
US

V. Phone/Fax

Practice location:
  • Phone: 770-509-1025
  • Fax: 770-509-1884
Mailing address:
  • Phone: 770-509-1025
  • Fax: 770-509-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN218921
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: