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General NPI Number Information
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NPI Number | 1649913138
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Entity Type | Individual
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Provider Name | ETHAN MATTHEW FAN
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Gender | Male
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Dates
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Enumeration Date | 04/14/2022
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 8200 WALNUT HILL LN
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City | DALLAS
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State | TX
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Zip | 75231-4402
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Country | US
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Telephone | 214-345-6176
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Fax | 214-345-5167
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Provider Business Mailing Address
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Address Line | 1140 PEACOCK BLVD
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City | CARROLLTON
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State | TX
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Zip | 75007-2943
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Country | US
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Telephone | 469-471-4848
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | W0570
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License Number State | TX
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