Healthcare Provider Details

I. General information

NPI: 1053108340
Provider Name (Legal Business Name): PATRICK SHEN CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 UNIVERSITY AVE
RIVERSIDE CA
92521-4836
US

IV. Provider business mailing address

777 N ASHLEY DR UNIT 1809
TAMPA FL
33602-4373
US

V. Phone/Fax

Practice location:
  • Phone: 909-475-2612
  • Fax:
Mailing address:
  • Phone: 727-417-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: