Provider Demographics
NPI:1497468607
Name:CHAN, KENNY
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12834 SE 41ST LN UNIT E101
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-1210
Mailing Address - Country:US
Mailing Address - Phone:206-214-6388
Mailing Address - Fax:
Practice Address - Street 1:13056 SE 76TH ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98056-4159
Practice Address - Country:US
Practice Address - Phone:425-386-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1-60067333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant