Provider Demographics
NPI:1487760351
Name:FAN, IAIN (DO)
Entity type:Individual
Prefix:
First Name:IAIN
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 1:2620 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:HELLERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18055-3312
Mailing Address - Country:US
Mailing Address - Phone:570-357-6163
Mailing Address - Fax:
Practice Address - Street 1:2620 EASTON RD
Practice Address - Street 2:
Practice Address - City:HELLERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18055-3312
Practice Address - Country:US
Practice Address - Phone:570-357-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202243012085R0202X
NY2022432085R0202X
PAOS009864L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1697024Medicaid
PA1697024Medicaid
PA013437Medicare ID - Type Unspecified