Provider Demographics
NPI:1710433610
Name:CHUNG, YICHEN (PT)
Entity Type:Individual
Prefix:
First Name:YICHEN
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 CANTON LOOP
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1429
Mailing Address - Country:US
Mailing Address - Phone:907-360-3648
Mailing Address - Fax:
Practice Address - Street 1:9500 CANTON LOOP
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515
Practice Address - Country:US
Practice Address - Phone:907-360-3648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK106666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1021187Medicaid
AKK161147Medicare PIN