Provider Demographics
NPI:1912196478
Name:ANDRIES, CHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:
Last Name:ANDRIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHAN
Other - Middle Name:
Other - Last Name:CHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:SURGERY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002002363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003020021Medicaid
CT003020021Medicaid