Healthcare Provider Details

I. General information

NPI: 1093184988
Provider Name (Legal Business Name): RYAN NICHOLAS CHAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 503
ORANGE CA
92868-3856
US

IV. Provider business mailing address

4044 SPRING LN
CORONA CA
92883-3698
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-2224
  • Fax: 714-997-1187
Mailing address:
  • Phone: 949-351-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number019033
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: