Provider Demographics
NPI:1386389146
Name:FAN, KEN-SHIH (DO)
Entity type:Individual
Prefix:
First Name:KEN-SHIH
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:594 NORTH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2591
Practice Address - Country:US
Practice Address - Phone:814-333-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program