Provider Demographics
NPI:1871689794
Name:CHAN, TERENCE T (MD)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:T
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5064
Mailing Address - Country:US
Mailing Address - Phone:360-493-4600
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:3417 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5064
Practice Address - Country:US
Practice Address - Phone:360-493-4600
Practice Address - Fax:360-493-4603
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000236532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0076574OtherL & I
WA1021195Medicaid
WA1016369Medicaid
WA0386386OtherL&I-RADIA REST OF WA
WA0381078OtherL&I-SOUTH SOUND RADIOLOGY
AC9325336OtherDEA NUMBER