Basic Information
| Provider Information | |||||||||
| NPI: | 1710636899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAN | ||||||||
| FirstName: | CHONG | ||||||||
| MiddleName: | SUP | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HAN | ||||||||
| OtherFirstName: | SCOTT | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747631 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.