Provider Demographics
NPI:1639953631
Name:TIEN, CHANDLER JAY
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:JAY
Last Name:TIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2984 WILLOWBROOK DR APT 5
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-1346
Mailing Address - Country:US
Mailing Address - Phone:415-572-9876
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program