Healthcare Provider Details

I. General information

NPI: 1972845790
Provider Name (Legal Business Name): JOHN L TAN II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 GALLETTI WAY
SPARKS NV
89431-5564
US

IV. Provider business mailing address

401 W 2ND ST SUITE 216
RENO NV
89503-5345
US

V. Phone/Fax

Practice location:
  • Phone: 775-688-2001
  • Fax:
Mailing address:
  • Phone: 775-682-8469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number16933
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: