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Recently Updated NPI Information — some details in this NPI profile have been updated in the NPI registry within the last 60 days.

TETRIS TAN MD
NPI 1104506005
Internal Medicine in Hesperia, CA

Active since July 25, 2023PECOS Enrolled
17089 MAIN ST, HESPERIA, CA 92345(760) 956-4123 Get Directions Write a Review

NPPES record last updated: September 21, 2026. Verified against the NPPES registry weekly; last sync: October 18, 2026.

Record update history: Sep 21, 2026, Aug 11, 2026, Jul 30, 2026 and 1 more (4 updates tracked since 2023).

About Tetris Tan Md NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

TETRIS TAN MD (NPI 1104506005) is an individual internal medicine provider in Hesperia, California, licensed in California (A209622) and active in the NPI registry since July 2023. She is enrolled in Medicare PECOS and is a graduate of Other (2020).

NPPES Registry Identity

NPI1104506005
Entity TypeIndividualFemale
Primary Taxonomy207R00000X
Provider Legal NameTETRIS TANCredential: MD
Location Address17089 MAIN STHesperia, CA 92345-6075
Mailing Address10554 Cannon DrRancho Cucamonga, CA 91730-0366
Phone(760) 956-4123
Sole ProprietorYes
Medical School CMSOtherGraduated 2020
Enumeration DateJuly 25, 2023
Last NPPES UpdateSeptember 21, 20264 updates tracked since enumeration
NPPES CertifiedSeptember 21, 2026
✔ NPI 1104506005 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyInternal MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207R00000X
License✔ Licensed in CA · A209622
Definition
A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. Internists are trained in the diagnosis and treatment of cancer, infections and diseases affecting the heart, blood, kidneys, joints and digestive, respiratory and vascular systems. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, mental health and effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs.
17089 MAIN ST, Hesperia, CA 92345
Open in Google Maps ↗

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Tetris Tan Md is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

PECOS PAC ID42779696
PECOS Enrollment IDI20260825002077
Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Medicare Billing Reassignment

Medicare enrollment records show Tetris Tan reassigns Medicare billing to 1 organization. The organization bills Medicare for the services this provider delivers there.

Providence Medical Foundation
4.5 mi
Urology
19333 BEAR VALLEY RD, SUITE 106
Apple Valley, CA 92308
  • Reassigned Medicare billing, California enrollment
  • 1,699 clinicians in this Medicare group
NPI 1053616706 (760) 240-5505

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 92345 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient
$136.04 typical visit price
range $59.60 – $179.42
Typical copayment $34.01 (range $14.90 – $44.85)
Most-billed visit code 99204
Established Patient
$104.64 typical visit price
range $19.37 – $146.42
Typical copayment $26.16 (range $4.84 – $36.60)
Most-billed visit code 99214
Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Tetris Tan's NPI number?

The NPI number for Tetris Tan is 1104506005. It was assigned to this individual provider in the NPPES registry on July 25, 2023.

Where is Tetris Tan located?

Tetris Tan practices at 17089 Main St, Hesperia, CA 92345. The listed phone number is (760) 956-4123.

What is Tetris Tan's specialty?

The primary specialty registered for this NPI is Internal Medicine with taxonomy code 207R00000X.

Is Tetris Tan enrolled in Medicare?

Yes. Tetris Tan is registered in the Medicare PECOS enrollment system.

Which organization bills Medicare for Tetris Tan's services?

According to the CMS Revalidation Reassignment List (October 2026 release), Tetris Tan reassigns Medicare benefits to Providence Medical Foundation (Apple Valley, CA). The reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Tetris Tan's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.

When was this NPI record last updated?

The NPPES record for Tetris Tan was last updated on September 21, 2026. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 30 days ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.