Provider Demographics
NPI:1467890178
Name:ELLEN FAN M D P A
Entity Type:Organization
Organization Name:ELLEN FAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-769-8572
Mailing Address - Street 1:3308 PRESTON RD
Mailing Address - Street 2:SUITE 350 BOX 242
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7453
Mailing Address - Country:US
Mailing Address - Phone:972-769-8572
Mailing Address - Fax:972-769-8591
Practice Address - Street 1:1301 RICHARDSON DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4648
Practice Address - Country:US
Practice Address - Phone:972-769-8572
Practice Address - Fax:972-769-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK88972084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179654201Medicaid
TX00731YMedicare PIN