Provider Demographics
NPI:1750551818
Name:CHAN, SOTHEARY (PA)
Entity type:Individual
Prefix:
First Name:SOTHEARY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-0218
Mailing Address - Country:US
Mailing Address - Phone:803-632-1176
Mailing Address - Fax:803-632-2410
Practice Address - Street 1:1787 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9133
Practice Address - Country:US
Practice Address - Phone:803-632-1176
Practice Address - Fax:803-632-2410
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical