Healthcare Provider Details

I. General information

NPI: 1588318703
Provider Name (Legal Business Name): JIE SHI YAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 E COLORADO BLVD STE 180
PASADENA CA
91101-6144
US

IV. Provider business mailing address

680 E COLORADO BLVD STE 180
PASADENA CA
91101-6144
US

V. Phone/Fax

Practice location:
  • Phone: 888-467-3910
  • Fax:
Mailing address:
  • Phone: 888-467-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JIE SHI YAN
Title or Position: OWNER
Credential:
Phone: 888-467-3910