Healthcare Provider Details

I. General information

NPI: 1700626652
Provider Name (Legal Business Name): MICKEY DE GUZMAN CHAN DMSC, MHSC, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 COLORADO AVE STE 160
TURLOCK CA
95382-2709
US

IV. Provider business mailing address

1801 COLORADO AVE STE 160
TURLOCK CA
95382-2709
US

V. Phone/Fax

Practice location:
  • Phone: 209-226-4299
  • Fax:
Mailing address:
  • Phone: 209-226-4299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA65304
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA65304
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: