Provider Demographics
NPI:1508424805
Name:CHANG, GRACE WEI-TING
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:WEI-TING
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-2402
Mailing Address - Fax:415-369-1292
Practice Address - Street 1:2100 WEBSTER ST STE 516
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2381
Practice Address - Country:US
Practice Address - Phone:415-600-2402
Practice Address - Fax:415-369-1292
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58793363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA58793OtherSTATE MEDICAL LICENSE