Healthcare Provider Details

I. General information

NPI: 1427023217
Provider Name (Legal Business Name): BETHANY BRAGDON TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/13/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6251 E VIRGINIA BEACH BLVD STE 300
NORFOLK VA
23502-2800
US

IV. Provider business mailing address

6251 E VIRGINIA BEACH BLVD STE 300
NORFOLK VA
23502-2800
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-5000
  • Fax: 757-962-5610
Mailing address:
  • Phone: 757-261-5000
  • Fax: 757-962-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD34085
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101056108
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD34085
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101056108
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: