Provider Demographics
NPI:1912059924
Name:CHAN, NIVES (PA)
Entity Type:Individual
Prefix:MS
First Name:NIVES
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 WINDSOR CENTRE TRL STE 400
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1865
Mailing Address - Country:US
Mailing Address - Phone:214-222-8150
Mailing Address - Fax:
Practice Address - Street 1:5204 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5829
Practice Address - Country:US
Practice Address - Phone:817-581-6100
Practice Address - Fax:817-581-6100
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20323045OtherDRIVER'S LICENSE