Provider Demographics
NPI:1831748045
Name:FAN, ADAM (DPT)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:SPOTSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08884-1241
Mailing Address - Country:US
Mailing Address - Phone:732-598-4647
Mailing Address - Fax:
Practice Address - Street 1:601 BOUND BROOK RD STE 201
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NJ
Practice Address - Zip Code:08846-2155
Practice Address - Country:US
Practice Address - Phone:732-968-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2022-09-07
Deactivation Date:2022-07-11
Deactivation Code:
Reactivation Date:2022-08-04
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01876500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist