MEDICARE: TRACEY E CHAN NP

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	363L00000X	Nurse Practitioner	4704220570	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710091376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY E CHAN NP

Provider Business Mailing Address
First Line	:	5555 CONNER ST
Second Line	:	STE 2691
City	:	DETROIT
State	:	MI
Zip	:	48213-3448
Country	:	US
Telephone Number	:	313-579-1182
Fax Number	:	313-579-5128

Provider Business Practice Location Address
First Line	:	5555 CONNER ST
Second Line	:	STE 2691
City	:	DETROIT
State	:	MI
Zip	:	48213-3448
Country	:	US
Telephone Number	:	313-579-1182
Fax Number	:	313-579-5128

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	05/10/2011

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Directions to “ TRACEY E CHAN NP” Practice Location

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