Healthcare Provider Details

I. General information

NPI: 1821583576
Provider Name (Legal Business Name): REX CHAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 CREEKSIDE DR STE 102
FOLSOM CA
95630-3820
US

IV. Provider business mailing address

3133 W MARCH LN STE 303
STOCKTON CA
95219-2336
US

V. Phone/Fax

Practice location:
  • Phone: 916-250-0377
  • Fax: 916-250-0378
Mailing address:
  • Phone: 209-464-3627
  • Fax: 209-464-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: