Basic Information
Provider Information | |||||||||
NPI: | 1912059924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAN | ||||||||
FirstName: | NIVES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300 WINDSOR CENTRE TRL STE 400 | ||||||||
Address2: |   | ||||||||
City: | FLOWER MOUND | ||||||||
State: | TX | ||||||||
PostalCode: | 750281865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2142228150 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5204 COLLEYVILLE BLVD | ||||||||
Address2: |   | ||||||||
City: | COLLEYVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 760345829 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175816100 | ||||||||
FaxNumber: | 8175816100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03081 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 20323045 | 01 | TX | DRIVER'S LICENSE | OTHER |