Provider Demographics
NPI:1245364231
Name:CHAN, JENNIFER NICOLE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICOLE
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 1:107 SUNFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-4110
Mailing Address - Country:US
Mailing Address - Phone:512-251-0532
Mailing Address - Fax:
Practice Address - Street 1:107 SUNFLOWER DR
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-4110
Practice Address - Country:US
Practice Address - Phone:512-251-0532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP06388Medicare UPIN