Provider Demographics
NPI:1588634331
Name:FAN, MICHELLE CHRISTIANA (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CHRISTIANA
Last Name:FAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:5950 SR6
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK,
Practice Address - State:PA
Practice Address - Zip Code:18457
Practice Address - Country:US
Practice Address - Phone:570-836-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009565L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001668739 0006Medicaid
PA0016687390007Medicaid
P00393423OtherRR MEDICARE
PAG56779Medicare UPIN
PA000789F4NMedicare PIN
PA000789N1GMedicare PIN