Healthcare Provider Details

I. General information

NPI: 1205195021
Provider Name (Legal Business Name): NINA CHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 E FOOTHILL BLVD STE 104
UPLAND CA
91786-4068
US

IV. Provider business mailing address

4950 SUNSET BLVD 4TH FLOOR
LOS ANGELES CA
90027
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number127505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: