Provider Demographics
NPI:1104906882
Name:HAN, CHUNG WAN
Entity type:Individual
Prefix:
First Name:CHUNG
Middle Name:WAN
Last Name:HAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 BACKLICK ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7201 BYRNELEY LN
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-6015
Practice Address - Country:US
Practice Address - Phone:703-354-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052584261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2215418OtherHMO
VA05812470Medicaid
VA05812470Medicaid