Provider Demographics
NPI:1639289614
Name:CHAN, FREDDY (PA)
Entity Type:Individual
Prefix:
First Name:FREDDY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5451 LA PALMA AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1730
Mailing Address - Country:US
Mailing Address - Phone:714-670-1340
Mailing Address - Fax:714-443-3780
Practice Address - Street 1:2063 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-6344
Practice Address - Country:US
Practice Address - Phone:323-796-0170
Practice Address - Fax:323-796-0220
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA17266363AM0700X, 363A00000X, 363AS0400X, 207RR0500X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17266OtherSTATE LICENSE NUMBER
CA00PA172660Medicaid
CAMC1088435OtherDEA#
CAQ17417Medicare UPIN