Basic Information
| Provider Information | |||||||||
| NPI: | 1740585421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | YUK CHIU | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| OtherLastName: | CHAN | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5603 PLEASANT AVE | ||||||||
| Address2: | |||||||||
| City: | PENNSAUKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081102840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095051834 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1123 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | MORGANVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077511261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326179797 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2011 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 25MP00245400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MA054446 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | C5-0000711 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 23-2389308 | 05 | NJ | MEDICAID |