Provider Demographics
NPI:1720283294
Name:FAN, KATHERINE W (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:W
Last Name:FAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4688 LA CRESCENT LOOP
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-2685
Mailing Address - Country:US
Mailing Address - Phone:408-427-2872
Mailing Address - Fax:
Practice Address - Street 1:20380 TOWN CENTER LN STE 215
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3250
Practice Address - Country:US
Practice Address - Phone:408-996-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429247208000000X, 2084P0800X, 2084P0804X
CAA1041142084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry