Healthcare Provider Details

I. General information

NPI: 1417059957
Provider Name (Legal Business Name): BRYAN PUI WANG CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 E FOOTHILL BLVD STE 104
UPLAND CA
91786
US

IV. Provider business mailing address

980 E FOOTHILL BLVD STE 104
UPLAND CA
91786
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-3578
  • Fax: 909-949-1238
Mailing address:
  • Phone: 909-920-3578
  • Fax: 909-949-1238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 7887
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number9007
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: