Provider Demographics
NPI:1992033898
Name:CHAN, BOPHA
Entity Type:Individual
Prefix:
First Name:BOPHA
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:PSC 482
Mailing Address - Street 2:BOX 2520
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-9998
Mailing Address - Country:US
Mailing Address - Phone:098-645-7372
Mailing Address - Fax:
Practice Address - Street 1:PSC 482
Practice Address - Street 2:BOX 2520
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-9998
Practice Address - Country:US
Practice Address - Phone:098-645-7372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI95963881710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman