Provider Demographics
NPI:1003900598
Name:FAN, MICHELLE KC (PHD (OMD))
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:KC
Last Name:FAN
Suffix:
Gender:F
Credentials:PHD (OMD)
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:FAN
Other - Last Name:NG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OMD
Mailing Address - Street 1:777 CAMPUS COMMONS ROAD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-929-6778
Mailing Address - Fax:916-929-6976
Practice Address - Street 1:777 CAMPUS COMMONS ROAD
Practice Address - Street 2:SUITE 160
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-929-6778
Practice Address - Fax:916-929-6976
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4484171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0044840Medicaid