Basic Information
| Provider Information | |||||||||
| NPI: | 1568791994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | ADDISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4012 WILD POPPY CT | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953568793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8312398371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 COFFEE RD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095264500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20A11051 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | R7410 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.