Provider Demographics
NPI:1295276509
Name:FAN, JUN
Entity type:Individual
Prefix:
First Name:JUN
Middle Name:
Last Name:FAN
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 1:1468 MADISON AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6508
Mailing Address - Country:US
Mailing Address - Phone:433-607-3934
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-241-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311553207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology