Basic Information
| Provider Information | |||||||||
| NPI: | 1134397870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | KENNY | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12021 WILSHIRE BLVD STE 745 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103481900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12021 WILSHIRE BLVD STE 745 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103481900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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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 | 173000000X | PA16068 | CA | N | Other Service Providers | Legal Medicine | 363A00000X | PA16068 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.