1417059957 NPI number — BRYAN PUI WANG CHAN MD

Table of content: BRYAN PUI WANG CHAN MD (NPI 1417059957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417059957 NPI number — BRYAN PUI WANG CHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
BRYAN
Provider Middle Name:
PUI WANG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1417059957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 E FOOTHILL BLVD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-920-3578
Provider Business Mailing Address Fax Number:
909-949-1238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 E FOOTHILL BLVD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-920-3578
Provider Business Practice Location Address Fax Number:
909-949-1238
Provider Enumeration Date:
09/04/2006

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: 171100000X , with the licence number:  AC 7887 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175L00000X , with the licence number: 9007 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A48504 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A485040 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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