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General NPI Number Information
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NPI Number | 1689729352
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Entity Type | Organization
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Legal Business Name | WESTLANE MEDICAL CLINIC,INC
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 03/03/2021
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Provider Practice Location Address
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Address Line | 4873 WEST LN SUITE A
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City | STOCKTON
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State | CA
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Zip | 95210-4548
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Country | US
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Telephone | 209-472-1515
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Fax | 209-472-1651
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Provider Business Mailing Address
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Address Line | 4873 WEST LN SUITE A
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City | STOCKTON
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State | CA
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Zip | 95210-4548
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Country | US
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Telephone | 209-472-1515
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Fax | 209-472-1651
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. GABRIEL KODZO TANSON
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Credential | M.D.
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Telephone | 209-472-1515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A325500
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License Number State | CA
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