MEDICARE: RICHARD D FAN PA

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	363A00000X	Physician Assistant	PA14813	CA

General Provider Information

NPI Number	:	1801963673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD D FAN PA

Provider Business Mailing Address
First Line	:	23041 AVENIDA DE LA CARLOTA FL 4
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1511
Country	:	US
Telephone Number	:	949-460-6637
Fax Number	:

Provider Business Practice Location Address
First Line	:	23041 AVENIDA DE LA CARLOTA FL 4
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1511
Country	:	US
Telephone Number	:	949-460-6637
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	06/22/2023

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