Provider Demographics
NPI:1477197911
Name:CHAN, KYLE (FNP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR FL 10
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-743-0670
Mailing Address - Fax:210-567-4659
Practice Address - Street 1:4502 MEDICAL DR FL 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-743-0670
Practice Address - Fax:210-567-4659
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405251601Medicaid
TX405251602OtherCSHCN