Provider Demographics
NPI:1376781799
Name:CHAN, KEITH MING (PT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MING
Last Name:CHAN
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 1:241 CONDO LN APT 602
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3144
Mailing Address - Country:US
Mailing Address - Phone:671-864-4778
Mailing Address - Fax:
Practice Address - Street 1:241 CONDO LN APT 602
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3144
Practice Address - Country:US
Practice Address - Phone:671-864-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35320225100000X
GU120225100000X
HI3952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH107545Medicare Oscar/Certification