Healthcare Provider Details

I. General information

NPI: 1013972371
Provider Name (Legal Business Name): SANDRA M KWAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 REID ST # A
JOINT BASE LEWIS MCCHORD WA
98431-1100
US

IV. Provider business mailing address

9040 REID ST # A
JOINT BASE LEWIS MCCHORD WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax: 253-968-3278
Mailing address:
  • Phone: 253-967-9818
  • Fax: 253-967-2639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00035389
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: