Provider Demographics
NPI:1104571801
Name:CHAN, ANGIE
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 20B
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY BLDG 20B
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2563
Practice Address - Country:US
Practice Address - Phone:631-864-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant