Provider Demographics
NPI:1043422421
Name:TAN, SANDA A (MD)
Entity type:Individual
Prefix:
First Name:SANDA
Middle Name:A
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 E JOHNSON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6065
Mailing Address - Country:US
Mailing Address - Phone:850-494-3749
Mailing Address - Fax:850-494-3974
Practice Address - Street 1:2130 E JOHNSON AVE STE 130
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6065
Practice Address - Country:US
Practice Address - Phone:850-494-3749
Practice Address - Fax:850-494-3974
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052098208C00000X
FLME99653208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279373300Medicaid
FLAG101ZMedicare PIN