Healthcare Provider Details

I. General information

NPI: 1649005414
Provider Name (Legal Business Name): AUSTIN CHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BETHANY DR STE C
SCOTTS VALLEY CA
95066-2803
US

IV. Provider business mailing address

125 BETHANY DR STE C
SCOTTS VALLEY CA
95066-2803
US

V. Phone/Fax

Practice location:
  • Phone: 844-322-7483
  • Fax: 888-334-7021
Mailing address:
  • Phone: 844-322-7483
  • Fax: 888-334-7021

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 StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: