Provider Demographics
NPI:1174197131
Name:NHAN, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:NHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1187
Mailing Address - Country:US
Mailing Address - Phone:707-638-5809
Mailing Address - Fax:
Practice Address - Street 1:1310 CLUB DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94592-1187
Practice Address - Country:US
Practice Address - Phone:707-638-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00000000000000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00000000000000Medicaid