Healthcare Provider Details

I. General information

NPI: 1184763195
Provider Name (Legal Business Name): JENNIFER CHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANDIA PLASTIC SURGERY 1020 TIJERAS AVE. NE
ALBUQUERQUE NM
87106-4749
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-6868
  • Fax: 505-842-9325
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2007-0451
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD2007-0451
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: