Healthcare Provider Details

I. General information

NPI: 1588895395
Provider Name (Legal Business Name): JENNY YU TAN ADULT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 BATHGATE AVENUE
BRONX NY
10457-4501
US

IV. Provider business mailing address

44 W 28TH ST FL 5
NEW YORK NY
10001-4212
US

V. Phone/Fax

Practice location:
  • Phone: 718-294-5891
  • Fax: 718-294-2468
Mailing address:
  • Phone: 212-545-2409
  • Fax: 212-463-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number30305090
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209007673
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: