Healthcare Provider Details

I. General information

NPI: 1427666304
Provider Name (Legal Business Name): MARION TAN DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 SALEM LAKE DR STE F
LONG GROVE IL
60047-5292
US

IV. Provider business mailing address

3880 SALEM LAKE DR STE F
LONG GROVE IL
60047-5292
US

V. Phone/Fax

Practice location:
  • Phone: 847-719-2220
  • Fax: 847-719-2265
Mailing address:
  • Phone: 847-719-2220
  • Fax: 847-719-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.456357
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.025913
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209025913
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: