Provider Demographics
NPI:1093184988
Name:CHAN, RYAN NICHOLAS (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:NICHOLAS
Last Name:CHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4044 SPRING LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-3698
Mailing Address - Country:US
Mailing Address - Phone:949-351-4006
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 503
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3856
Practice Address - Country:US
Practice Address - Phone:714-997-2224
Practice Address - Fax:714-997-1187
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019033363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1128223OtherNCCPA
CA57966OtherPHYSICIAN ASSISTANT