Provider Demographics
NPI:1518049014
Name:CHAN, FANNY W (OD)
Entity Type:Individual
Prefix:
First Name:FANNY
Middle Name:W
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 PRATER WAY
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-4466
Mailing Address - Country:US
Mailing Address - Phone:775-356-3937
Mailing Address - Fax:775-356-0808
Practice Address - Street 1:738 PRATER WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-4466
Practice Address - Country:US
Practice Address - Phone:775-356-3937
Practice Address - Fax:775-356-0808
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1316460001OtherMC DMERC
NV33574OtherMEDICARE PART B
NV410043037OtherRAILROAD MEDICARE
NV002507626Medicaid
NV11026OtherMES, WMCA
NV15186OtherMES,LOVELOCK
NV15186OtherMES,LOVELOCK
NV002507626Medicaid