Provider Demographics
NPI:1134157860
Name:TANAKA, NILS (MD)
Entity type:Individual
Prefix:DR
First Name:NILS
Middle Name:
Last Name:TANAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1403
Mailing Address - Street 2:
Mailing Address - City:SUMMERLAND
Mailing Address - State:CA
Mailing Address - Zip Code:93067-1403
Mailing Address - Country:US
Mailing Address - Phone:805-565-3231
Mailing Address - Fax:
Practice Address - Street 1:700 ALAMO PINTADO RD
Practice Address - Street 2:
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-2269
Practice Address - Country:US
Practice Address - Phone:805-688-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57654207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93486Medicare UPIN
CAFH063ZMedicare PIN