Healthcare Provider Details

I. General information

NPI: 1104086594
Provider Name (Legal Business Name): ANDY CHAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 E VALLEY PKWY
ESCONDIDO CA
92025-3008
US

IV. Provider business mailing address

606 E VALLEY PKWY
ESCONDIDO CA
92025-3008
US

V. Phone/Fax

Practice location:
  • Phone: 760-740-4215
  • Fax: 760-740-4003
Mailing address:
  • Phone: 760-740-4215
  • Fax: 760-740-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number704401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: