MEDICARE: STEPHANIE ANNE POWAO TAN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	038789-01	NY
2	225100000X	Physical Therapist	086271	IA

General Provider Information

NPI Number	:	1740865500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ANNE POWAO TAN PT, DPT

Provider Business Mailing Address
First Line	:	1150 PELHAM PKWY S APT 6C
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-1032
Country	:	US
Telephone Number	:	646-620-6488
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 HAVEMEYER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-5382
Country	:	US
Telephone Number	:	718-863-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2021
Last Update Date	:	03/13/2021

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