Provider Demographics
NPI:1811619349
Name:TAN, JACQUELINE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 MOORPARK AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2655
Mailing Address - Country:US
Mailing Address - Phone:408-286-1707
Mailing Address - Fax:
Practice Address - Street 1:2211 MOORPARK AVE STE 130
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2655
Practice Address - Country:US
Practice Address - Phone:408-286-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64013207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty