Healthcare Provider Details

I. General information

NPI: 1770159949
Provider Name (Legal Business Name): JUSTIN TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 DECARIE BLVD
MONTREAL QUEBEC
H4A 3J3
CA

IV. Provider business mailing address

5399 CEDARBRIDGE WAY APT. 621
RICHMOND BRITISH COLUMBIA
V6X0L6
CA

V. Phone/Fax

Practice location:
  • Phone: 514-369-0688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMD472529
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: