Healthcare Provider Details

I. General information

NPI: 1023206216
Provider Name (Legal Business Name): JASON STEFAN CHAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 S PUUNENE AVE STE 108
KAHULUI HI
96732-2192
US

IV. Provider business mailing address

PO BOX 700127
KAPOLEI HI
96709-0127
US

V. Phone/Fax

Practice location:
  • Phone: 808-877-5657
  • Fax: 808-877-5659
Mailing address:
  • Phone: 808-949-9585
  • Fax: 808-748-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-381
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1080343
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1080343
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1080343
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: