Provider Demographics
NPI:1649412321
Name:KAN, JUSTIN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ANDREW
Last Name:KAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CALYX LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008
Mailing Address - Country:US
Mailing Address - Phone:505-506-3138
Mailing Address - Fax:
Practice Address - Street 1:50 CALYX LN
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008
Practice Address - Country:US
Practice Address - Phone:505-506-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0251207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine