1104906882 NPI number — CHUNG WAN HAN

Table of content: CHUNG WAN HAN (NPI 1104906882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104906882 NPI number — CHUNG WAN HAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAN
Provider First Name:
CHUNG
Provider Middle Name:
WAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1104906882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5105 BACKLICK ROAD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ANNANDALE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7201 BYRNELEY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-6015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-354-9222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2006

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: 261QP2300X , with the licence number:  0101052584 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2215418 . This is a "HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 05812470 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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