Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 58.001840 | OH |
Y | 207QS0010X | Family Doctor - Sports Medicine | 35-009402 | OH |
NPI | 1336344746 |
---|---|
Provider Name | Christopher Tangen |
First Address | Belfast, ME 04915-8792 |
Second Address | Richmond Hts, OH 44143-1116 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2007 |
Last Update Date | 30/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2954576 | (05) | OH |