Provider Demographics
NPI:1902041718
Name:CHAN, GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 774
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3848
Mailing Address - Country:US
Mailing Address - Phone:312-942-6642
Mailing Address - Fax:312-738-9763
Practice Address - Street 1:1725 W HARRISON ST STE 774
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3848
Practice Address - Country:US
Practice Address - Phone:312-942-6642
Practice Address - Fax:312-738-9763
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant