Provider Demographics
NPI:1407213234
Name:FAN, VIOLA (DPT, PT, MS)
Entity Type:Individual
Prefix:DR
First Name:VIOLA
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:DPT, PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HUCKLEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-1264
Mailing Address - Country:US
Mailing Address - Phone:626-383-7006
Mailing Address - Fax:
Practice Address - Street 1:1800 SULLIVAN AVE
Practice Address - Street 2:RM 504
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2225
Practice Address - Country:US
Practice Address - Phone:415-812-2826
Practice Address - Fax:626-593-2311
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist