Provider Demographics
NPI:1376741256
Name:CHAN, JACK SUI KI (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:SUI KI
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N TOWN CENTER DR UNIT 1033
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0577
Mailing Address - Country:US
Mailing Address - Phone:517-899-5453
Mailing Address - Fax:
Practice Address - Street 1:1350 N TOWN CENTER DR UNIT 1033
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0577
Practice Address - Country:US
Practice Address - Phone:517-899-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60179402207P00000X
MI4301090230207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8903513Medicare PIN