Provider Demographics
NPI:1508240680
Name:CHEN, CONNIE Y (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:Y
Last Name:CHEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S DETROIT ST APT 108
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3546
Mailing Address - Country:US
Mailing Address - Phone:510-853-1596
Mailing Address - Fax:
Practice Address - Street 1:607 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3211
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:323-268-9119
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant