Provider Demographics
NPI:1336306083
Name:CHAN, KENNETH KIAN-LIP (MSPA PAC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:KIAN-LIP
Last Name:CHAN
Suffix:
Gender:M
Credentials:MSPA PAC
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Mailing Address - Street 1:11 BISHOP PLACE
Mailing Address - Street 2:OCCUPATIONAL HEALTH DEPT B3
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901
Mailing Address - Country:US
Mailing Address - Phone:732-932-8254
Mailing Address - Fax:732-932-8254
Practice Address - Street 1:11 BISHOP PLACE
Practice Address - Street 2:OCCUPATIONAL HEALTH DEPT B3
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-932-8254
Practice Address - Fax:732-932-8254
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2010-04-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00098600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ173474UA1Medicare PIN