Provider Demographics
NPI:1235114141
Name:PHAN, CHAU (PT)
Entity Type:Individual
Prefix:
First Name:CHAU
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E CIVIC CENTER DR APT 1019
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-0010
Mailing Address - Country:US
Mailing Address - Phone:310-430-9791
Mailing Address - Fax:
Practice Address - Street 1:3336 E CHANDLER HEIGHTS RD STE 126
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298
Practice Address - Country:US
Practice Address - Phone:480-840-6125
Practice Address - Fax:480-840-6122
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27275225100000X
AZLPT300262251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT27275AMedicare PIN