=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982742250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN CALIFORNIA PODIATRY ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 03/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 4TH ST SUITE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-2107
-----------------------------------------------------
Fax | 707-573-0315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1041 4TH ST SUITE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-2107
-----------------------------------------------------
Fax | 707-573-0315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. EMILIZA NGO TAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 707-546-2107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | E4045
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------