Provider Demographics
NPI:1720016983
Name:CHAN, KYLE (PAC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SUNNYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4822
Mailing Address - Country:US
Mailing Address - Phone:516-932-8584
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-267-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2165320Medicaid
NYP36827Medicare UPIN
NY2165320Medicaid