Provider Demographics
NPI:1710091376
Name:CHAN, TRACEY E (NP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:E
Last Name:CHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 CONNER ST
Mailing Address - Street 2:STE 2691
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3448
Mailing Address - Country:US
Mailing Address - Phone:313-579-1182
Mailing Address - Fax:313-579-5128
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:STE 2691
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-579-1182
Practice Address - Fax:313-579-5128
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704220570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4956148Medicaid
MIN88860010Medicare ID - Type Unspecified
MI4956148Medicaid