MEDICARE: JACKYLN WAI-SHAN CHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A130711	CA

General Provider Information

NPI Number	:	1447544333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKYLN WAI-SHAN CHAN M.D.

Provider Business Mailing Address
First Line	:	2707 E VALLEY BLVD STE 215
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3197
Country	:	US
Telephone Number	:	909-594-3382
Fax Number	:

Provider Business Practice Location Address
First Line	:	2707 E VALLEY BLVD STE 215
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3197
Country	:	US
Telephone Number	:	909-594-3382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	07/17/2020

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