Provider Demographics
NPI:1912920430
Name:CHAN, WAN HOR (MD)
Entity Type:Individual
Prefix:MR
First Name:WAN
Middle Name:HOR
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W I ST STE C
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3460
Mailing Address - Country:US
Mailing Address - Phone:209-826-4771
Mailing Address - Fax:209-826-8565
Practice Address - Street 1:600 W I ST STE C
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3460
Practice Address - Country:US
Practice Address - Phone:209-826-4771
Practice Address - Fax:209-826-8565
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76229ZMedicaid
CAA24554Medicare UPIN