Provider Demographics
NPI:1003284811
Name:CHAN, KELSEY (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:LUTCHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:875 TULAROSA
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1118
Mailing Address - Country:US
Mailing Address - Phone:516-263-5675
Mailing Address - Fax:
Practice Address - Street 1:14443 CULVER DR STE A
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0343
Practice Address - Country:US
Practice Address - Phone:949-767-8173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1128187OtherNCCPA