Basic Information
| Provider Information | |||||||||
| NPI: | 1134186034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | KA WAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8109 FREDERICKSBURG RD | ||||||||
| Address2: | PHYSICIAN PRACTICE SERVICES | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105752222 | ||||||||
| FaxNumber: | 2105756373 | ||||||||
| Practice Location | |||||||||
| Address1: | 4410 MEDICAL DR | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105752222 | ||||||||
| FaxNumber: | 2105756373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 05/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | J2535 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 208000000X | J2535 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | J2535 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0207X | J2535 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8CC910 | 01 | BCBS | OTHER | 130467713 | 05 | TX | MEDICAID | 130467714 | 01 | TX | CSN | OTHER |