Healthcare Provider Details

I. General information

NPI: 1457731358
Provider Name (Legal Business Name): SUSAN LEI TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PUNAHOU ST STE 1120
HONOLULU HI
96826-1089
US

IV. Provider business mailing address

1407 HOCKADAY STREET
COQUITLAM BC
V3E2X3
CA

V. Phone/Fax

Practice location:
  • Phone: 808-983-6447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number18013
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number18013
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number18013
License Number StateHI
# 4
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number18013
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: