Provider Demographics
NPI:1467844019
Name:CHAN, BRIAN REBENQUE (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:REBENQUE
Last Name:CHAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MINERAL KING AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6237
Mailing Address - Country:US
Mailing Address - Phone:941-979-7614
Mailing Address - Fax:
Practice Address - Street 1:400 W MINERAL KING AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:941-979-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX868861367500000X
CANA95000403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered