Provider Demographics
NPI:1679210694
Name:CHAN, ETHAN NORIN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:NORIN
Last Name:CHAN
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 1:58 KENYON RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:698 BANK ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5040
Practice Address - Country:US
Practice Address - Phone:860-772-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPTT15131183700000X
MAPI167939390200000X
CTPCI.0010039390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183700000XPharmacy Service ProvidersPharmacy Technician