Provider Demographics
NPI:1386907947
Name:CHAN, EMILIA JUNE IMUTAN (SAS, MED)
Entity type:Individual
Prefix:MRS
First Name:EMILIA JUNE
Middle Name:IMUTAN
Last Name:CHAN
Suffix:
Gender:F
Credentials:SAS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 RADCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4015
Mailing Address - Country:US
Mailing Address - Phone:917-640-0773
Mailing Address - Fax:347-621-5806
Practice Address - Street 1:1624 RADCLIFF AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4015
Practice Address - Country:US
Practice Address - Phone:917-640-0773
Practice Address - Fax:347-621-5806
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist