Provider Demographics
NPI:1487988804
Name:TAN, JEROME ALDRIN ENRIQUE
Entity type:Individual
Prefix:MR
First Name:JEROME ALDRIN
Middle Name:ENRIQUE
Last Name:TAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STOKES RD APT 2B
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-5941
Mailing Address - Country:US
Mailing Address - Phone:914-202-7708
Mailing Address - Fax:
Practice Address - Street 1:4915 BROADWAY APT 4P
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3162
Practice Address - Country:US
Practice Address - Phone:917-669-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016103-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist