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General NPI Number Information
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NPI Number | 1134314362
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Entity Type | Organization
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Legal Business Name | WILSON H LUY TAN, MD LTD
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 705 S UNIVERSITY AVE SUITE 380
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City | BEAVER DAM
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State | WI
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Zip | 53916-3053
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Country | US
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Telephone | 920-887-3460
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Fax | 920-887-3491
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Provider Business Mailing Address
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Address Line | 705 S UNIVERSITY AVE SUITE 380
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City | BEAVER DAM
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State | WI
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Zip | 53916-3053
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Country | US
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Telephone | 920-887-3460
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Fax | 920-887-3491
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Authorized Official
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Title or Position | PRESIDENT
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Name | WILSON H LUY TAN
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Credential | M.D.
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Telephone | 920-887-3460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 28716-020
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License Number State | WI
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