Healthcare Provider Details

I. General information

NPI: 1083901110
Provider Name (Legal Business Name): GRACE L. TSAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2011
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE NEW MEXICO VA HEALTH CARE SYSTEM
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

718 HAWKINS WAY
ALEXANDRIA VA
22314-6200
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 703-508-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3407ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: