Healthcare Provider Details

I. General information

NPI: 1528464658
Provider Name (Legal Business Name): MA. CRISTINA CRISTOBAL TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 S ALASKA ST
TACOMA WA
98408-1317
US

IV. Provider business mailing address

8409 59TH STREET CT W
UNIVERSITY PLACE WA
98467-4059
US

V. Phone/Fax

Practice location:
  • Phone: 253-476-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT60418014
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: