Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | G077865 | CA |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | G077865 | CA |
N | 2081P2900X | Pain Medicine | G077865 | CA |
NPI | 1801850953 |
---|---|
Provider Name | Dr. Jackie Tsz-Kit Chan |
First Address | Modesto, CA 95350-1500 |
Second Address | Modesto, CA 95350-1500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2006 |
Last Update Date | 03/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BC4731041 | DEA NUMBER (01) | |
G43677 | (02) |