Provider Demographics
NPI:1679881254
Name:CHAN, CARRIE (NP)
Entity Type:Individual
Prefix:MISS
First Name:CARRIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 SAN PABLO ST
Mailing Address - Street 2:SUITE 3800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5310
Mailing Address - Country:US
Mailing Address - Phone:323-442-6962
Mailing Address - Fax:323-442-7705
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 3800
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-6962
Practice Address - Fax:323-442-7705
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535036363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA535036OtherLICENSE