Provider Demographics
NPI:1245803592
Name:CHAN, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CHAN
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 1:13610 BOOTH MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5010
Mailing Address - Country:US
Mailing Address - Phone:929-786-0888
Mailing Address - Fax:929-322-9669
Practice Address - Street 1:13610 BOOTH MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5010
Practice Address - Country:US
Practice Address - Phone:929-786-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care