Healthcare Provider Details

I. General information

NPI: 1063243111
Provider Name (Legal Business Name): AMANDA CHAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8268 164TH ST STE 1B02
JAMAICA NY
11432-1104
US

IV. Provider business mailing address

8268 164TH ST STE 1B02
JAMAICA NY
11432-1104
US

V. Phone/Fax

Practice location:
  • Phone: 718-883-3070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number032247
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: