Healthcare Provider Details

I. General information

NPI: 1669835773
Provider Name (Legal Business Name): JESSICA LI-YAN CHOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 02/13/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST
SANTA MONICA CA
90404-1249
US

IV. Provider business mailing address

1100 GLENDON AVE STE 1200
LOS ANGELES CA
90024-3516
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-0585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA155117
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberA155117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: