Provider Demographics
NPI:1942565783
Name:CHAN, KA PUI ELIZA
Entity Type:Individual
Prefix:
First Name:KA PUI ELIZA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E 6TH ST,
Mailing Address - Street 2:ODESSA REGIONAL MEDICAL CENTER
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761
Mailing Address - Country:US
Mailing Address - Phone:432-582-8381
Mailing Address - Fax:
Practice Address - Street 1:520 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4527
Practice Address - Country:US
Practice Address - Phone:432-582-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82194133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered