Provider Demographics
NPI:1720371644
Name:CHAN, AMY W (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:CHAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 AGNEW RD
Mailing Address - Street 2:APT. 221
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-1502
Mailing Address - Country:US
Mailing Address - Phone:408-229-3243
Mailing Address - Fax:
Practice Address - Street 1:800 CALIFORNIA ST
Practice Address - Street 2:#120
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-2809
Practice Address - Country:US
Practice Address - Phone:408-229-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14350171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist