Provider Demographics
NPI:1790002293
Name:FAN, JOHNNY (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 LAGUNA HONDA BLVD
Mailing Address - Street 2:F5
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1411
Mailing Address - Country:US
Mailing Address - Phone:415-682-1744
Mailing Address - Fax:
Practice Address - Street 1:375 LAGUNA HONDA BLVD
Practice Address - Street 2:F5
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-1411
Practice Address - Country:US
Practice Address - Phone:415-682-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist