1518049014 NPI number — FANNY W CHAN O.D.

Table of content: FANNY W CHAN O.D. (NPI 1518049014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518049014 NPI number — FANNY W CHAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
FANNY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518049014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
738 PRATER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89431-4466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-356-3937
Provider Business Mailing Address Fax Number:
775-356-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
738 PRATER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89431-4466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-356-3937
Provider Business Practice Location Address Fax Number:
775-356-0808
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  319 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1316460001 . This is a "MC DMERC" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 33574 . This is a "MEDICARE PART B" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 410043037 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 002507626 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11026 . This is a "MES, WMCA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 15186 . This is a "MES,LOVELOCK" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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