Provider Demographics
NPI:1093184988
Name:CHAN, RYAN NICHOLAS (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:NICHOLAS
Last Name:CHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:22431 ANTONIO PKWY # B160-613
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2804
Mailing Address - Country:US
Mailing Address - Phone:855-727-2251
Mailing Address - Fax:855-727-2251
Practice Address - Street 1:22431 ANTONIO PKWY # B160-613
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2804
Practice Address - Country:US
Practice Address - Phone:855-727-2251
Practice Address - Fax:855-727-2251
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019033363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57966OtherPHYSICIAN ASSISTANT
1128223OtherNCCPA